A recent review of fertility preservation in trans and intersex people was published in the new journal Transgender Health. It’s a topic only briefly addressed previously on Open Minded Health (in trans 101 for trans people). Using the review as inspiration then, this week I’ll cover options and factors to consider when it comes to having biological children.

The basic technique in fertility treatments is the harvesting of sperm or eggs. Those sperm or eggs can then be frozen for later use or used for fertility treatments such as in vitro fertilization. For this to work, ovaries or testes have to be producing those eggs and sperm. This means the person has to be past their natal puberty and produce enough viable eggs and sperm that they can be harvested.

For transgender adults, sperm/eggs are best harvested before any hormones are taken. Hormones do reduce fertility, although they are not considered reliable enough to be used as birth control. The amount of estrogens or testosterone needed to have an impact on fertility is currently unknown, but it seems to be different for everyone. So your safest bet is to store egg/sperm before beginning hormones if you can afford it and if having a biological child in the future is important to you. Surgical removal of ovaries/uterus/testes does, of course, make a person sterile and unable to have future biological children.

Trans men who still have a uterus can carry a child but need to be off testosterone to do so as testosterone is harmful to fetal growth. Transgender women cannot carry children with current medicine.

For transgender youth it’s more complex. If the youth hasn’t gone through their natal puberty (e.g., for someone assigned female at birth that would be a female puberty) enough to have fertile sperm/eggs, then they have no sperm/eggs to harvest. Going from pre-puberty to puberty blockers to gender-appropriate hormone therapy means that, with today’s technology, there is no future fertility for the youth. If the youth has been on puberty blockers only, the blockers can be removed and the youth allowed to go far enough into natal puberty so that sperm/eggs can be harvested, and then transition. However going through natal puberty is often traumatic for trans youth, and may not be worth it for the youth. There are experimental options currently being used for children with cancer — taking ovarian or testicular tissue from the child and freezing it for future use. However it’s very experimental and I don’t know of anyone doing it for trans youth at this time.

With trans youth there is the added concern of ethical decision making. Children and adolescents cannot give informed consent. That’s the job of the parents or legal guardians. But their desires may clash with that of the youth, possibly causing harm. Depending on the family the question of fertility may or may not be problematic.

For intersex people or people with differences of sexual development, the effect on fertility depends on the specifics of the medical condition. But there are some larger concepts we can talk about. First — being intersex does not automatically mean a person has no fertility. Many of the intersex medical conditions do result in lower fertility. The potential treatment depends on what’s actually causing the low fertility.

If the ovary/testis itself is considered “abnormal” (e.g., a mosaic ovary), the effect on fertility is often failure of the ovary/testis. In this case, there’s little that modern medicine can do. The person can try the experimental preservation technique of harvesting and freezing ovarian/testicular tissue, but that’s an experimental technique.

If the root cause is hormonal (e.g., congenital adrenal hyperplasia), then it’s possible that sperm/eggs can be harvested. Hormonal treatment may also help fertility.

If the root cause is a higher risk of ovarian/testicular cancer, fertility preservation depends on whether the person is pre- or post- puberty. Treatment for an ovary/testicle that has a high risk of becoming cancerous is removal of that ovary/testicle. So if the person has already gone through puberty and is about to have the organ removed, sperm/eggs can be harvested before. If they are pre-pubertal, they can try the experimental technique of freezing the tissue.

Genetic counseling may also be useful for intersex people, as some differences of sexual development conditions are genetic and can be passed down to biological children. Intersex people should receive fertility counseling from physicians knowledgeable in their particular condition at as young an age as possible to maximize their options.

Lastly — never forget that having biological children isn’t the only way to have children. Adoption, fostering, and co-parenting are all wonderful things and are not any less valid ways to have children than having a biological one. If the laws in your state allow, consider adopting, fostering, or co-parenting.

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