Transgender patients face barriers and stigma over fertility preservation, say experts

Outcomes for transgender persons who undergo fertility preservation are improving, but barriers remain within pre-conception and pre-natal care.

Data presented by Chloë De Roo on persons assigned female at birth (AFAB) suggests a similar number of oocytes are retrieved, no difference in response to ovarian stimulation, and increasing reports of live births.

However, Dr De Roo, from the University of Gent, Belgium, said the primary focus on women or femininity within pregnancy-related care, coupled with societal attitudes, creates difficulties for trans persons AFAB and for healthcare providers.

She said: “A need exists for more trans-specific information and scientific knowledge regarding pregnancy-related care. It’s important to communicate with these patients and their partners because they feel left aside.”

Reproductive care for trans patients involves fertility preservation and (assisted) reproduction because more patients are choosing not to undergo gender-affirming surgery.

In her talk, Dr De Roo cited data from a paper, on which she was lead author, that analysed the effects of gender-affirming hormone treatment (GAHT) on reproduction and fertility. This showed that blind spots remain in knowledge on the impact of GAHT, a testosterone-based approach which can limit future reproductive options if individuals desire to either give birth or become a biological parent.

Ovaries exposed to androgens show histologic changes resembling those in polycystic ovaries eg increased cortical stiffness and cystic follicles. Endometrial thickness is significantly lower, suggesting an absence of endometrial proliferation.

On a positive note, Dr De Roo highlighted that some follicular activity still persists despite GAHT, and that oocyte retrieval and ovarian stimulation outcomes are comparable with those of cisgender females.

As yet unpublished data show persons AFAB are more likely to use frozen gametes, with results showing around a quarter of participants AFAB surveyed have used or are using frozen oocytes to conceive.

Future use of preserved gametes depends on factors such as quality and if gender affirming surgery took place. If uterus is removed then she said it’s difficult to conceive, explained Dr De Roo.

Feelings of regret around fertility preservation is low in general, with persons AFAB more likely to express dissatisfaction.

Experiences of care though is more negative within pregnancy-related spaces, as outlined by Dr De Roo. A lack of maternity clothing for trans men was among complaints along with fear of procedures such as vaginal ultrasound from patients. Language and ideas can result in “transphobia, discrimination and distress”, said Dr De Roo.

Discussions are also needed among clinicians and trans patients around effective contraception. There is a tendency to focus on surgery and harms of progesterone, but Dr De Roo said exogenous testosterone is not an adequate means of birth control.

Moreover, population screening invitations are based on an individual’s registered gender. This means those for cervical cancer and breast cancer are only sent to persons registered as women. In a call to action, Dr De Roo urged clinicians to ensure they support trans patients for the entire care journey.

An update on fertility preservation in persons assigned male at birth (AMAB), including for adolescents, was given by Florian Schneider from St Franziskus Hospital, Germany.

Fertility protection is important with trans women wanting their sperm frozen, their own biological children and medical teams to take care of preserving fertility, according to evidence presented by Dr Schneider. Trans people express regret at not having taken steps to preserve their fertility before undergoing gender-affirming surgery.

In his conclusion, Dr Schneider said ‘personalised and person-centred solutions’ were needed for fertility preservation in persons AMAB including the provision of fertility counselling by experts at reproductive medicine centres.

Other messages from his talk were that fertility preservation should be thought about as early as possible, and the topic of fertility preservation should be brought up repeatedly, especially during childhood and adolescence.

Reference

– C De Roo et al. Fertility in transgender and gender diverse people: systematic review of the effects of gender-affirming hormones on reproductive organs and fertility. Hum Reprod Update, vol 31 (3) May-June 2025; 183–217; https://doi.org/10.1093/humupd/dmae036