Fertility Preservation Options for the LGBT Community by Dr. Marcus Jurema
Fertility Preservation and Family Building Options for the Transgender and Transsexual Communities
Recent surveys of transgender and transsexual individuals, in different stages of the process, revealed that most people agree with the need for healthcare providers to bring up fertility preservation as an option prior to initiating medical or surgical therapies. Old school thinking preached the notion that for a complete transsexual transition one should absolutely part with the old and embrace the new. For example, that storing frozen sperm prior to a male to female change would be a sign of doubt or might interfere with the psychological commitment to the process. This view point is no longer embraced, and current advice involves presenting the option of fertility preservation to anyone contemplating a transsexual transition, independent of age.
Nowadays, several strategies for successfully accomplishing preservation of fertility in both men and women are readily available. Traditionally, the concept of preserving one’s gametes (eggs or sperm) for future use has been applied to cancer patients facing treatment that will render them infertile. Drawing from this concept, the transgender and transsexual communities have utilized the availability of fertility preservation prior to hormonal or surgical procedures necessary for the transition process.
Fertility preservation and family building options differ depending on the direction of transition, i.e. male to female or female to male, the type of relationship one would have after the transition (lesbian, bisexual, gay, or straight) as well as the gender of the current and/or future partner. In addition, options vary according to the stage of the process, i.e., pre- or post- hormonal and/or surgical therapies. In order to make the right decision, it is advisable for those considering a sex change procedure to seek the advice of a fertility specialist, since every situation is unique.
First, let’s consider someone considering a male to female transition.
Prior to starting any treatment (hormonal or surgical), banking a frozen sperm sample, multiple samples if possible, would be ideal. There are several commercial banks available for this purpose. If the person is currently partenered with a woman, traditional conception may be an option. If this route is chosen and the female partner is older than 35 years, the couple should seek the preconception advice of a fertility specialist to consider expediting conception and evaluating factors that could be interfering with fecundity especially if they have already been trying for more than 6 months (12 months if the female partner is younger than 35 years old). If the partner is male, then in vitro fertilization (IVF) with an egg donor and a gestational carrier (GC) would be necessary. Again, fertility specialists and clinics are able to coordinate all aspects of this process.
After the initiation of a male to female transition, if banked sperm is available and the partner is female, a simple procedure done at the fertility clinic called intra-uterine insemination (IUI) can be performed. If only hormonal treatment is being used in the transition process, it is possible to temporarily halt the treatment to allow sperm recovery from the testicles to generate enough semen to then use in a fresh IUI, or to reconsider freezing semen samples for future use. If the transition is already in the surgical stages then semen could only be obtained after hormonal recovery using a surgical technique to extract sperm cells from the testicles, this is turn, does not produce enough sperm for IUI and would require IVF which is more involved and expensive, but offers high success rates.
If the partner is male, then the transsexual woman could consider IVF with an egg donor and use sperm from the partner and/or the woman either through ejaculation or surgical retrieval to create embryos to be transferred into a GC. Most elite IVF clinics are equipped with a team of doctors, nurses and staff , and offer a concierge style of treatment to handle the demands and coordinate the needs of couples seeking help in situations like these, which is often referred to as “third-party reproduction”.
Now let’s switch gears and consider the female to male transition options.
Prior to starting any treatment (hormonal or surgical), single or individuals without a partner, could consider attempting conception through the use of donor sperm IUI. Donor sperm IUI is also an option to be performed on the non-transitioning partner if she is female. If partnered with a man, traditional conception attempts should be considered, keeping in mind the age of the female partner, that is, if she is older than 35 years and trying to conceive for more than 6 months, a visit to a fertility specialist is suggested (or if she is younger than 35 years and trying to conceive for more than 12 months). These more traditional approaches to conception are advisable to consider simply in light of the high costs of fertility treatment associated with the other options.
If the above options are not desirable, and the person in transition is single or not in a permanent relationship, then freezing eggs to be stored and used in the future by fertilizing them with donor sperm IVF or a potential future male partner IVF is an option that carries very high success rates but is highly dependent on the age of the transsexual man when the eggs were frozen (the younger the better). If the transsexual woman is in a currently desirable and stable relationship with a man then pre-embryos (fertilized eggs) can be stored instead of eggs. The same can be done using donor sperm to fertilize the eggs and freeze the pre-embryos for future use. Freezing embryos is the most established and reliable IVF-related strategy for fertility preservation to date, and offers the highest success rates for a future pregnancy.
In the future, if the transsexual man partners with another man then the frozen embryos or eggs (after fertilization) can be transferred into a GC. On the other hand if the partner is a woman then the same could be transferred into her uterus through a process called a frozen embryo transfer. Alternatively, a transsexual man could accept transfer of the embryos into his own uterus if he has not had a hysterectomy, and he is willing to reverse the masculinizing hormonal effects.
After the transition process has been initiated with hormones, a transsexual man could temporarily stop therapy to allow resumption of ovulation for traditional conception, donor sperm IUI, egg freezing, or embryo freezing options. Obviously, consideration is given to the fact that interruption of hormonal therapy reverses all the feminizing effects achieved while on the hormones. Furthermore, a transsexual man in interrupted hormonal treatment could even consider transferring his own embryos into his uterus if the use of a GC is financially prohibitive (in total it could cost between US $40,000- $100,000). Transsexual man contemplating surgery to remove ovaries and/or uterus could give thought to preserving whole ovaries or pieces of ovarian tissue. This technology is in its infancy and has not been very successful to date but holds promise for the future.
In general, the decision to preserve eggs and/or embryos should be made as early as possible, ideally before the age of 30 and certainly before the age of 35.
In conclusion, there are many options for the transgender and transsexual couples interested in fertility preservation and family building. In fact there are so many options and scenarios that couples are often confused and overwhelmed, not to mention the added stress of the financial implications of some of these options. Fortunately, most well established IVF centers are prepared to support and help couples and individuals seeking these options to go through the process as easily as possible. Finally, current standard of care dictates that transpatients must be informed about their options regarding fertility preservation and future family building prior to initiating treatment. In addition, this conversation should take place independent of the age of the individual and should never be misconstrued as evidence of ambivalence about one’s trans identity.
IVF New Jersey is proud to have been working with the LGBT community since 1990.