The decision to pursue fertility preservation can be an important one for transgender, or trans, men (an umbrella term for those who were assigned female at birth but who identify as male or masculine). Physicians who see transmasculine patients, including nonbinary people, shouldn't assume that the transition process means that this population is forgoing parenthood. Getting up to speed on transgender fertility needs can help clinicians inform young people about their family planning options.
Understanding Transgender Fertility
The gender journey is different for everyone: Some transmasculine people may transition socially by changing their name and outward presentation. Others may take hormones to change their physical characteristics, which can result in the growth of facial and body hair, increased muscle mass and a deeper voice. Some choose to undergo surgical procedures to align their body with their gender identity, including chest reconstruction (commonly known as top surgery), hysterectomy, vaginectomy (surgical removal of the vagina), metoidioplasty and phalloplasty (surgical formation of a penis).
These changes don't always affect fertility. Transmasculine patients who use testosterone typically stop ovulating and menstruating; however, the effect of long-term testosterone therapy on ovarian function remains unclear, and trans men can become pregnant. One study published in Obstetrics and Gynecology found that out of 41 participants who had given birth after transitioning, 61 percent had previously used testosterone. This highlights an important opportunity for physicians to counsel transmasculine patients who do not wish to become pregnant about their birth control options.
Exploring Options for Transgender Men's Fertility Preservation
At the same time, the conversation about transgender fertility is also crucial for patients who hope to conceive in the future. The World Professional Association for Transgender Health (WPATH) standards of care advise that physicians discuss fertility preservation methods with trans patients as part of the informed consent process.
Oocyte cryopreservation is one option for fertility preservation that allows trans men to preserve their eggs before undergoing hormone treatment or surgery. Eggs that were retrieved and frozen can later be used to establish a pregnancy in a patient's partner or gestational carrier.
Ovarian tissue cryopreservation, an increasingly common fertility preservation option for those undergoing cancer treatment, may also be viable for men and nonbinary people who wish to someday carry a pregnancy themselves. Transmasculine patients who have a uterus, ovaries and a vagina may become pregnant spontaneously or through IVF after discontinuing testosterone, although research on this matter is sparse. Ideally, fertility preservation should occur before a patient begins hormone therapy.
Ultrasound and Trans Patient Care: Sensitivity and Terminology
Ultrasound-guided oocyte retrieval and cryopreservation is a clinically established mode of fertility preservation in trans men, but its success does not preclude discomfort in some patients.
Even undergoing a routine transvaginal ultrasound exam can be traumatic for some trans patients. Although more research is needed, one small study in Human Reproduction found that the genital examinations and physical changes that can accompany fertility preservation can sometimes trigger gender dysphoria.
Gynecologists can help ease these feelings of discomfort and distress by using gender-neutral language ("gestational parent" instead of "mother"), nongendered names for body parts ("chest" instead of "breasts") and every patient's personally specified gender pronouns.
Since a "low level of healthcare provider awareness" was also a common experience for the Obstetrics and Gynecology study participants, clinicians should make an effort to expand their definition of who can carry a pregnancy and give birth, and to improve their knowledge of trans patients' unique care needs.
Some transmasculine patients may benefit from counseling and the support of family and friends while they are undergoing fertility preservation. Just as with any other patient, communication is key for gynecologists who wish to help trans men navigate their fertility options.
