Fertility preservation is routinely recommended for all TGD people pursuing medical gender affirmation. In practice, however, very few TGD people follow this recommendation due to a range of barriers, including prohibitive costs, limited access, time constraints,dysphoria-related concerns, and insufficient guidance from medical providers. Additionally, many TGD people and their healthcare providers may be misinformed about the actual impact HRT has on fertility. At the same time, reproductive technologies are also rapidly advancing, creating new possibilities for creating families.
What is Fertility Preservation?
Fertility preservation is an umbrella term for several biomedical technologies that store reproductive cells and enable someone to have biological children at a later time. Fertility preservation is recommended for people undergoing treatment for a number of medical conditions from cancers to auto-immune disorders, including gender dysphoria. A growing number of cisgender women are also choosing to store their eggs without a specific medical reason, giving reasons like waiting for the right partner or wanting to advance their career before having children (Lee et al., 2026).
There are three main ways that reproductive cells can be stored:
- Egg/ sperm freezing- After retrieving a sample, egg or sperm cells are stored in a deep freeze. This is the most common form of fertility preservation, particularly for TGD people who are young, single, and don’t have major health issues.
- Embryo freezing- After eggs or sperm are removed from a donor, they can be combined to create a fertilized egg. Lab technicians will then carefully monitor the developing embryos and freeze them when they reach a specific stage of growth. These embryos can then be implanted into the uterus and develop into healthy pregnancies. You can’t use this method if you don’t have egg and sperm available. This means it may not be right for people who are unsure who they want to have children with yet.
- Ovarian/ testicular freezing- During this form of fertility preservation, a surgeon removes an ovary or testicle (whole or in several small pieces) and freezes it. This option is newer and was developed for cancer patients who may not be able to delay treatment to store reproductive cells. More research is needed, but this method is promising for TGD people because it could theoretically be completed at the same time as bottom surgeries (Sterling & Garcia, 2020). This may also be a good option for children who haven’t gone through natal puberty. Before puberty, the reproductive organs are not fully developed and may not be able to produce eggs or sperm for freezing.
Regardless of the type of preservation, all samples are stored in extremely cold liquid nitrogen tanks and are usable for 10+ years (Johns Hopkins Medicine, 2023). Stored eggs, sperm, or embryos can later be used in Assistive Reproductive Technologies (ART) like in vitro fertilization (IVF) and intrauterine insemination (IUI) to create a viable pregnancy. Stored ovarian/ testicular tissue can be reimplanted into the donor’s body to enable conception through sex, or used with other forms of ART.
Why is it important for TGD people?
Like all people, many transgender people want to have genetic children. One small study (Auer et al., 2018) found that roughly one in four (¼) TGD people who’ve started HRT want to have children in the future. Additionally, nearly 19% of TGD people are already parents (Carone at al., 2021). While more research is needed, gender-affirming medical treatments may make it more difficult to have genetic children. Fertility counseling and preservation is recommended for all TGD people before starting HRT. Despite this, only 9.6% of trans women and 3.1% of trans men had preserved egg or sperm cells before beginning HRT (Auer et al., 2018).
There are many likely factors that contribute to this. First, fertility preservation and treatments are rarely covered by health insurance in the US and can be prohibitively expensive; while highly variable, the total cost to conceive can exceed $50,000 (Cagle, 2025). Second, many healthcare providers don’t feel informed enough or qualified to discuss fertility preservation with their clients/ patients (Tishelman et al., 2019). While WPATH recommends discussing fertility preservation with all TGD patients before starting HRT, there are no specific guidelines on when or how to do so. Lastly, many countries and US states used to require surgical sterilization to change gender markers on IDs. While these laws are slowly being overturned, they have had a lasting impact on assumptions about trans people’s fertility and desires to become parents.
What do we know about HRT and fertility?
Despite the recommendation for fertility preservation, we know surprisingly little about the impact of HRT on fertility. As of 2020, there were no studies about how long-term HRT use affects egg and sperm development and health (Sterling & Garcia, 2020). While we once thought HRT would make someone permanently sterile, researchers are beginning to think of reproductive function as suppressed or paused by HRT (Nie et al., 2023). Still, unintended pregnancy is relatively common in the trans community; up to 30% of trans men have had an unintended pregnancy compared to 41% of the relevant US population (Verbanas, 2019; CDC, 2024). A few studies suggest that trans women may produce lower quality sperm samples than cisgender men, especially when on HRT (Li et al., 2018; Rodriguez-Wallberg et al., 2021). However, sperm health seems to return to pre-HRT norms after pausing treatment for around 4 months (Adeleye et al., 2019). One study has found no significant differences in the number or quality of eggs retrieved from trans men who had previously been on testosterone compared to those who had never taken it (Cromack et al., 2024).
What do we know about gender affirming surgeries and fertility?
The impacts of gender-affirming surgery on fertility are much more clear. Any procedure that changes the structure of the genitals or reproductive organs will make someone unable to conceive, carry, or deliver their own genetic children through sex.
This includes all bottom surgeries, like:
- Orchiectomy
- Vaginoplasty
- Oophorectomy
- Hysterectomy
- Metoidioplasty
- Phalloplasty
- Nullification Surgeries/ Nulloplasty
What is the fertility preservation process like?
For transgender women and nonbinary people AMAB the sperm donation and preservation process is relatively simple. You’ll typically take your own sample by masturbating and collecting the ejaculate (cum) in a small, sterile cup. If using a traditional fertility clinic, you’ll give your sample in a small, private room inside the office. Options to collect your own sample at home and mail it to the preservation site are also becoming more common. If dysphoria or erectile dysfunction mean that collecting your own sample isn’t an option, a doctor may be able to extract it from the testicles in a simple outpatient procedure. After the sample is received, lab technicians will extract the sperm and perform tests to make sure it will be able to produce a healthy pregnancy. The sperm are then frozen and stored.
For transgender men and nonbinary people AFAB fertility preservation requires much more medical supervision and effort. It’s currently recommended to stop taking testosterone at least 8 weeks before beginning the fertility preservation process. After the menstrual cycle returns, there will be 2 weeks of injecting medications, including hormones typically produced during pregnancy. These medications can cause PMS-like symptoms including mood swings, hot flashes, tenderness in the chest/ breasts, and bloating. To prepare for egg retrieval, the fertility specialist may also need to perform a transvaginal ultrasound. During this procedure, a long, narrow probe will be inserted into the vagina to look at the uterus and ovaries. Lastly, during the egg retrieval procedure, the patient will be under anesthesia while the doctor inserts a large, hollow needle through the internal wall of the vagina to access the ovaries and eggs. This can be an intensely dysphoric process, before considering pregnancy and birth. For some trans men and enbies AFAB repeated pelvic exams can trigger intense anxiety and panic attacks. Getting mental health support throughout the process is recommended. A doctor or psychiatrist may also be able to prescribe anxiety medications for exams.
Conclusion
Many TGD people want to become parents, but face a number of personal and systemic barriers to doing so. Medical research remains unclear about the long-term effects HRT can have on fertility. Healthcare providers need more information, education, and resources to support their TGD patients. Fertility preservation offers an opportunity to have genetic children in the future. There are three main methods of fertility preservation for TGD people- egg/ sperm freezing; embryo freezing; and ovarine/ testicular tissue freezing. Each method will collect a sample of reproductive cells and store them in a deep freeze. The reproductive cells can then be thawed and used in other Assistive Reproductive Technologies, like IVF.
Fertility and parenthood decisions are deeply personal and deserving of compassionate, evidence-based support from healthcare providers, regardless of gender identity.
References
Adeleye, A. J., Reid, G., Kao, C.-N., Mok-Lin, E., & Smith, J. F. (2019). Semen Parameters Among Transgender Women With a History of Hormonal Treatment. Urology, 124, 136–141. https://doi.org/10.1016/j.urology.2018.10.005
Auer, M. K., Fuss, J., Nieder, T. O., Briken, P., Biedermann, S. V., Stalla, G. K., Beckmann, M. W., & Hildebrandt, T. (2018). Desire to Have Children Among Transgender People in Germany: A Cross-Sectional Multi-Center Study. The Journal of Sexual Medicine, 15(5), 757–767. https://doi.org/10.1016/j.jsxm.2018.03.083
Cagle, P. (2025, April 25). IVF Cost and Procedure Guide. https://www.carecredit.com/well-u/health-wellness/ivf-pricing/
Carone, N., Rothblum, E. D., Bos, H. M. W., Gartrell, N. K., & Herman, J. L. (2021). Demographics and health outcomes in a U.S. probability sample of transgender parents. Journal of Family Psychology: JFP: Journal of the Division of Family Psychology of the American Psychological Association, 35(1), 57–68. https://doi.org/10.1037/fam0000776
Cromack, S. C., Walter, J. R., Smith, K. N., Elvikis, J., Bazzetta, S. E., & Goldman, K. N. (2024). Oocyte Cryopreservation in Transgender and Gender-Diverse Individuals With or Without Prior Testosterone Use. Obstetrics & Gynecology, 144(6), e121. https://doi.org/10.1097/AOG.0000000000005749
de Nie, I., van Mello, N. M., Vlahakis, E., Cooper, C., Peri, A., den Heijer, M., Meißner, A., Huirne, J., & Pang, K. C. (2023). Successful restoration of spermatogenesis following gender-affirming hormone therapy in transgender women. Cell Reports Medicine, 4(1), 100858. https://doi.org/10.1016/j.xcrm.2022.100858
Johns Hopkins Medicine. (2023, February 17). Freezing Embryos. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/freezing-embryos
Lee, M. B., Siavoshi, M., Kwan, L., & Kroener, L. (2026). Elective fertility preservation: A national database study on trends in oocyte cryopreservation and oocyte utilization over a 5- to 7-year follow-up period. American Journal of Obstetrics and Gynecology, 234(2), 432–439. https://doi.org/10.1016/j.ajog.2025.08.032
Li, K., Rodriguez, D., Gabrielsen, J. S., Centola, G. M., & Tanrikut, C. (2018). Sperm Cryopreservation of Transgender Individuals: Trends and Findings in the Past Decade. Andrology, 6(6), 860–864. https://doi.org/10.1111/andr.12527
Rodriguez-Wallberg, K. A., Häljestig, J., Arver, S., Johansson, A. L. V., & Lundberg, F. E. (2021). Sperm quality in transgender women before or after gender affirming hormone therapy-A prospective cohort study. Andrology, 9(6), 1773–1780. https://doi.org/10.1111/andr.12999
Sterling, J., & Garcia, M. M. (2020). Fertility preservation options for transgender individuals. Translational Andrology and Urology, 9(Suppl 2), S215–S226. https://doi.org/10.21037/tau.2019.09.28
Tishelman, A. C., Sutter, M. E., Chen, D., Sampson, A., Nahata, L., Kolbuck, V. D., & Quinn, G. P. (2019). Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: Qualitative responses to an international survey. Journal of Assisted Reproduction and Genetics, 36(3), 579–588. https://doi.org/10.1007/s10815-018-1395-y
Verbanas, P. (2019, August 15). Pregnant Transgender Men at Risk for Depression and Lack of Care, Rutgers Study Finds. https://www.rutgers.edu/news/pregnant-transgender-men-risk-depression-and-lack-care-rutgers-study-finds