Transgender women have several reproductive options depending on their transition stage, fertility status, and personal circumstances. These include unassisted conception, intrauterine insemination (IUI), and in vitro fertilization (IVF), either with a partner who has a uterus or with a gestational carrier. While uterine transplants may one day allow trans women to carry pregnancies, this remains experimental and years away.
Unassisted conception is possible if estrogen therapy has not begun or after temporarily stopping hormones, though natural conception rates are typically low. IUI, which involves inserting sperm directly into a partner’s uterus, may work if sperm was banked before transition or if enough sperm can be produced after pausing hormone therapy. Success depends largely on the carrier’s age and overall fertility.
IVF involves fertilizing eggs in a lab and transferring embryos to the uterus. It’s costly and may require multiple cycles, but donor eggs or sperm can improve success rates. Fertility preservation before transition remains the best strategy for future family planning.
A gender-affirming transition, including hormone therapy and surgery, can significantly affect fertility. It’s best to consider these impacts before beginning the transition process.
During transition, many trans women take estrogen and/or androgen blockers. Estrogen can severely reduce or even permanently damage sperm production. In some cases, sperm production may partially recover after stopping estrogen for three to six months, but the amount is usually very small. As a result, natural conception is unlikely, and assisted reproductive technologies such as intrauterine insemination (IUI) or in vitro fertilization (IVF) are often required.
There is limited research on how long one should discontinue estrogen to regain sperm or how exposure duration affects recovery. Since a sperm production cycle takes about three months, providers typically suggest waiting at least that long.
Gender-affirming surgeries that involve removing the testes permanently end fertility unless sperm or testicular tissue is preserved beforehand.
Fertility preservation is an important consideration for transgender women, as hormones like estrogen can significantly reduce fertility, and surgeries that remove the testes permanently eliminate sperm production. Preserving fertility before transition greatly increases the chances of future conception through treatments like IUI or IVF.
The ideal time to consider fertility preservation is before starting hormone therapy, though options may still exist afterward. Studies show that even before transition, trans women often have lower sperm counts and quality compared to cisgender men, making semen analysis essential before freezing sperm.
The most common method is sperm freezing, which costs around $400–$1,000, with annual storage fees. Freezing multiple samples improves future treatment options and reduces the need for emotionally difficult “de-transitioning.”
Mail-in sperm freezing kits offer privacy, though medical follow-up is still needed. For those unable to ejaculate, experimental testicular tissue freezing may one day make laboratory-grown sperm possible, offering hope for future IVF use.
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