Fertility preservation and realignment in transgender women

Figures & data

Figure 1. Global prevalence of gender dysphoria. TG: transgender

Table 1. Fertility aspirations and influencing factors in transgender women.

Author and year	Participants	Source of participants	Age (years)	Fertility aspirations	Influencing factors
Youths and Adolescents (age <18)
Persky et al. (2020)	64 transgender and gender diverse youths	Hospital based gender clinic (USA)	Mean age 16.8	20% of participants perceived having children to be important	Discomfort with reproductive anatomy Unwillingness to delay gender transition
Chiniara et al. (2019)	79 transgender individuals: 64 assigned female at birth 15 assigned male at birth	Transgender youth clinic (Canada)	Age 12–18 5/15 between the age of 13–15 9/15 between the age of 16-18	10/15 (67%) would like to be a parent Only 1/15 would be frustrated if could not have a biological child 12/15 would consider adopting	Highest priority was “being in good health” Fertility preservation was ranked as the lowest priority All participants were aware of the impact of hormonal therapy on future fertility None of the participants assigned as male at birth would consider fertility preservation if it caused a delay in starting hormonal therapy
Chen et al. (2018)	156 transgender and non-conforming adolescents	Online survey Participants recruited through paid advertisement via Facebook (United States)	Age 14–17	48.7% interested in having children some day 35.9% interested in having biological children	79% never discussed fertility preservation with a healthcare professional 82.7% did not have counselling regarding how hormonal therapy could impair fertility Adoption perceived as a reasonable option Concerns regarding stigma associated with parenthood as a sexual and gender minority Concerns regarding feelings associated with pregnancy, parenthood and gender identity
Strang et al. (2018)	25 transgender males and females: 14 transgender males 10 transgender females 1 nonbinary	Gender Development Program (United States)	Age 13–19	84% of participants ranked understanding how hormone treatment might affect fertility as important 100% already knew that hormonal treatment could impact future fertility 56% expressed a preference for having children	Having biological children was not rated as important 96% would consider adoption Only 36% would consider medical procedures for fertility preservation
Brik et al. (2019)	35 transgirls	Curium-Leiden University Medical Centre (Netherlands)	Mean age 14.8	7/15 (20%) transgirls interested in having children 32/35 (91%) counselled about impact on fertility	Some participants did not want children Interests in adoption Feeling uncomfortable with masturbation Feeling uncomfortable with the idea of being the biological father of a child
Kyweluk et al. (2018)	6 transgender individuals assigned male at birth	Gender and Sex Development Program clinic (Chicago, USA)	Age <20	Not specified	Concerns regarding limitations of future use of cryopreserved sperm The necessity for a donor egg and surrogate Inability to carry a pregnancy feeling like a constraint
Adults (age >18)
Riggs and Bartholomaeus (2018)	409 transgender or non-binary adults	Online questionnaire via social media (Facebook/Twitter)	Mean age 28.54 (range 18–72)	64 already had children, of which 12 wish to have more (18.8%) 345 did not have children, of which 114 (33%) would like to in the future	162/244 (66%) respondents did not feel genetic relatedness was important
Auer et al. (2018)	99 transgender women 90 transgender men	Transgender health care centre (Germany)	Median age 41	When asked before commencing gender affirmation treatment, 65.4% of transgender women could imagine having children	Having genetically identical children was only important for a minority of transgender women. A lack of counselling was not deemed to influence desires.
Pfäfflin et al. (2002)	121 transgender/ transexual women	Online survey (Netherlands, Belgium, France, and UK)	Adults age >20 (70% between the age of 30 and 50)	Those with no children: 40% would not want more, 40% would like more, 20% unsure Those already with children: 50% would not want more children, 40% would want children, 10% unsure	90% did not feel fertility loss was an important reason to delay transition 50% felt having biological children was important and 50% did not Difficulties in masturbation Pronounced feelings of gender dysphoria associated with freezing of sperm and difficulties
Millar et al. (2015)	12 transgender people	Endocrine, psychiatric and family planning clinics (Canada)	Age 19–25	5/12 (42%) desired to have children	6/12 (50%) had fertility options discussed 8/12 (67%) felt that sperm banking was costly

Where possible, results reported individual for transgender women. If not specified by authors, results reported for transgender men and women together.

Table 2. Fertility preservation uptake rates and prohibiting factors in transgender women.

Author and year	Participants	Source of participants	Age (years)	Fertility preservation counselling	Fertility preservation uptake	Reasons
Sermondade et al. (2021)	118 Patients referred for fertility preservation counselling	Transgender women who contacted the Assisted Reproductive Technology Centre (Tenon University Hospital, Paris)	23.9–35.1	22/118 (19%) cancelled their appointments 96/118 ((81%) attended counselling	13/96 (14%) Did not proceed with fertility preservation 83/96 (86%) attempted sperm collection	Not specified
Rodriguez-Wallberg et al. (2021)	212 Referrals of transgender women for fertility preservation	Individuals referred to fertility preservation services (Karolinska University Hospital, Sweden)	24 (median)	212	33/212 (16%) Did not proceed with fertility preservation	Not specified
Nahata et al. (2017)	73	Single large academic paediatric centre	15.2 (median)	72/73 (99%) underwent counselling	2/73 (3%) Took up preservation	Desires to adopt (45.2%) No desire to have offspring (21.9%) Cost concerns (8.2%) Would find masturbation uncomfortable (1.4%) Unwilling to delay treatment (1.4%)
Brik et al. (2019)	35 Transgirls	Curium-Leiden University Medical Centre (Netherlands)	Mean age 14.8	32/35 (91%) counselled about impact on fertility	12/35 (38%) Attempted fertility preservation (of those that received fertility counselling)	Younger and Caucasian transgirls less likely to take up fertility preservation No reason for declining fertility preservation in 33% 32% unable to produce semen sample (due to early puberty) 17% uncomfortable with masturbation 17% did not want children 13% preference for adoption
Chen et al. (2017)	13 Transgender individuals: 7 transgender men 6 transgender women	Individuals seeking hormonal therapy at the Gender & Sex Development Program (USA)	Aged between 14.2 and 20.6 (mean age for transgender women = 17.2)	13/105 (12.4%) transgender adolescents underwent formal fertility preservation counselling	4/6 (67%) Transgender women completed sperm cryopreservation	Reported mistreatment and misgendering by sperm bank technician Not interested in having children
Pang et al. (2020)	112 Transgender individuals 53 transgender women 49 transgender men	Individuals on GnRHa or gender affirming hormones in a paediatric gender service clinic (Australia)	Mean age 15.6 (range 10.8–18.3)	112/112 underwent counselling	33/53 (62%) Of transgender women underwent fertility preservation 22/33 had sperm cryopreservation 11/33 had testicular biopsies	Did not want biological children Interest in adoption Did not want children Did not want to supply a masturbatory sample
Riggs and Bartholomaeus (2018)	409 Transgender or non-binary adults	Online questionnaire via social media (Facebook/Twitter)	Mean age 28.54 (range 18–72)	70/308 (22.7%) received advice or counselling about future fertility options	370/398 (93%) Did not take up fertility preservation 28/398 (7%) did take up fertility preservation	68% of those that did not take up fertility preservation, did not receive any counselling The most common probative factor was cost. The thought of having children as inducing feelings of dysphoria was also reported.
Segev-Becker et al. (2020)	106 Transgender males and females (age <18): 9 prepubertal transgender females 38 pubertal transgender females	Paediatric Gender Dysphoria Clinic (Israel)	Median age at referral 15.5 (range 4.6–18)	All patients received counselling	14 (45%) Pubertal transgender females underwent fertility preservation	Not specified
C.A Jones et al. (2016)	11 Transgender females	Fertility clinic (Canada)	Mean age 26.4 (range 20-40)	All patients received counselling	9/11 (82%) Underwent fertility preservation (sperm cryopreservation)	Financial costs Low likelihood of achieving pregnancy
Auer et al. (2018)	99 Transgender women 90 transgender men	Transgender health care centre (Germany)	Median age 41	95/99 (96%) Transgender women received counselling	10/99 Transgender women utilised fertilisation preservation	One third of transgender women considered fertility preservation before gender affirming hormonal treatment, however did not proceed due to technical factors. Only 5/99 women were dissuaded by financial reasons
Riggs et al. (2018)	409 Transgender or non-binary adults	Online questionnaire via social media (Facebook/Twitter)	Mean age 28.54 (range 18–72)	70/308 (22.7%) Transgender adults received advice or counselling about future fertility preservation options	7% Had undertaken fertility preservation	Financial cost Not interested in having children The process of having children would exacerbate feelings of gender dysphoria Already had children Avoid delay in transition
Pfäfflin et al. (2002)	121 Transgender/ transexual women	Online survey (Netherlands, Belgium, France and UK)	Adults age >20 (70% of participants were between the age of 30 and 50)	Proportion of participants who received fertility preservation counselling not specified However, 77% felt sperm cryopreservation should be offered to all prior to hormonal therapy	Only 51% would have considered sperm freezing if it were a possible option	Psychological difficulties with masturbation Pronounced feelings of gender dysphoria associated with freezing of sperm Financial costs Perception that gender dysphoria would make them bad parents

Where possible, results reported individual for transgender women. If not specified by authors, results reported for transgender men and women together.

GnRHa: Gonadotrophin releasing hormone analogues.

Figure 2. Available methods of fertility preservation for transgender women and influencing factors.

Persky, R. W., Gruschow, S. M., Sinaii, N., Carlson, C., Ginsberg, J. P., & Dowshen, N. L. (2020). Attitudes toward fertility preservation among transgender youth and their parents. The Journal of Adolescent Health : Official Publication of the Society for Adolescent Medicine, 67(4), 583–589. https://doi.org/10.1016/j.jadohealth.2020.02.027

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Strang, J. F., Jarin, J., Call, D., Clark, B., Wallace, G. L., Anthony, L. G., Kenworthy, L., & Gomez-Lobo, V. (2018). Transgender youth fertility attitudes questionnaire: Measure development in nonautistic and autistic transgender youth and their parents. The Journal of Adolescent Health : Official Publication of the Society for Adolescent Medicine, 62(2), 128–135. https://doi.org/10.1016/j.jadohealth.2017.07.022

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