March 15, 2022
Reproductive endocrinology and infertility specialists at Mayo Clinic's campus in Rochester, Minnesota, now offer services bridging a gap in an underserved population: fertility preservation for transgender individuals. There are well-established methods of preserving fertility in these patients, says Zaraq Khan, M.B.B.S., a reproductive surgeon and chair of Reproductive Endocrinology and Infertility.
Dr. Khan hopes to increase physician awareness about applicable fertility preservation services for the transgender population. Aware that relevant medical literature on this topic was scant, Dr. Khan and colleagues published a Mayo Clinic Proceedings review article, intentionally submitting to a journal with a broad physician audience, in 2020.
Defining and identifying transgender individuals
Dr. Khan doesn't define transgender by bodily changes but as how an individual self-identifies — such as male, female or nonbinary.
"For transgender people, the gender they relate to is not the gender assigned at birth," says Dr. Khan. "It's not anatomical: Individuals may be anywhere on the transgender spectrum and have undergone gender-affirming surgery or not."
Given this broad transgender definition plus underreporting of transgender status, identifying transgender individuals is challenging, Dr. Khan says. He explains that U.S. documents usually request that individuals select male or female as their gender status, though some agencies have begun to include a "do not wish to disclose" category.
Providing options for later infertility
Dr. Khan explains that reproductive endocrinology and infertility specialists have adopted oncology-related fertility preservation methods for transgender individuals because of insufficient transgender population data. Scarce data directly relate to socioeconomic challenges and inadequate health care access for this group, he explains.
"Fertility preservation for transgender individuals is something I value," he says. "At Mayo Clinic, we want to provide help and attention for gender affirmation — and also the bonus layer of fertility preservation. Our team wants to provide patients hope for a typical life. It's exciting to participate in saving someone's ability to conceive."
Yet Dr. Khan reports that transgender individuals often are surprised to learn about the potential of fertility preservation. "They have no idea this is a possibility," he says. "They're just trying to get peace for who they are. For most, fertility preservation isn't even on their radar."
The Mayo Clinic Proceedings article reports that interest in having children is often higher for trans men compared with that for trans women prior to gender-affirming treatment; factors influencing this interest are unknown. Dr. Khan says further research is warranted to study transgender individuals' fertility-related thinking processes.
Fertility preservation methods
Dr. Khan and team conduct fertility preservation for transgender people in a process similar to that used for cisgender individuals. For trans men, Dr. Khan indicates that oocyte or embryo cryopreservation is ideal. This involves controlled ovarian stimulation (COS) with injectable fertility medication or an oral-injectable medication combination and then ultrasound monitoring. Though scant literature exists about COS after gender-affirming hormone therapy with high-dose testosterone, there seem to be no long-term detrimental risks to the ovaries from testosterone, he says.
Although stopping testosterone therapy is not needed in all cases, Dr. Khan and team theorize that longer therapy abstention — about three months — could allow ovarian stimulation to resume, prompting ideal follicular growth. For trans women, the team uses sperm or testicular tissue cryopreservation, which Dr. Khan notes is less complex than fertility preservation for trans men. He recommends that trans women take an estrogen therapy hiatus as well to increase sperm count, if needed.
Although no fertility preservation age restrictions exist for transgender individuals, Dr. Khan and colleagues don't often see transgender children. Individuals in this age group usually are undergoing pubertal blocker treatment and haven't yet had gender affirmation therapy.
Fertility preservation barriers for the transgender population
Various issues hamper fertility preservation services for transgender individuals:
Fear of medical professionals' misunderstanding or bias
The Mayo Clinic Proceedings study found concerns about misconception to be critical barriers to seeking fertility care.
Lack of finances and insurance coverage for medical services
Because many transgender individuals have been evicted from their homes by parents or are otherwise homeless, even primary care access is often an issue. Though a few payers have launched health insurance coverage for transgender individuals, many transgender individuals don't have hormonal therapy coverage, much less coverage for fertility preservation. Paying cash for egg freezing is a particular hurdle, as it's more costly than semen collection.
Insufficient fertility preservation counseling
Dr. Khan hypothesizes that the medical community doesn't often counsel transgender patients about fertility preservation services. A doctoral student on Dr. Khan's team currently is studying this hypothesis along with the factors influencing the fertility preservation decisions of transgender people.
Gender dysphoria and anxiety about the process
Some patients may require a three-month gender affirming hormone therapy pause before fertility preservation, and the process can remind them of a gender they're renouncing. "Generally, this population just wants to arrive at gender affirmation super-fast," says Dr. Khan. "Fertility preservation can trigger defense mechanisms or denial — some deeply rooted issues." Dr. Khan explains, for example, that trans men don't want estrogen, which is common in cisgender female fertility preservation. If they've undergone testosterone therapy, physicians could prescribe temporary hormone abstention or add medication counteracting the therapy's infertility-causing effects.
Due to potential gender-related psychological issues inherent to fertility preservation in a population already experiencing gender incongruence, psychologists at Mayo Clinic provide counseling during the process.
Fertility preservation outcomes and impact for transgender individuals
Dr. Khan explains that minimal outcomes literature exists due to the relatively new availability of fertility preservation for transgender people. Furthermore, few published articles exist regarding trans men who retain a uterus and can carry a pregnancy. Stigma about this practice still exists, however, even within the transgender community, he says.
With successful live infant delivery, another anxiety and dysphoria-producing topic arises for trans men: chestfeeding capability. "Chestfeeding for this group is not simple," says Dr. Khan. "Few medical providers understand it yet."
The Mayo Clinic Proceedings paper cites existing data demonstrating mixed fertility preservation experiences for the transgender population due to dysphoria and minimal physician awareness about this group and its nuances.
Considerations for the medical community
Dr. Khan believes that health care providers seeing transgender patients have pivotal roles: ensuring fertility-preservation education, regardless of position on the transgender spectrum, and informing about specialty medical providers for the procedure.
"This is about understanding a new area of medicine to give our best to this population," he says. "Everybody brings characteristics physicians need to acknowledge. We're trying to create awareness and education about transgender people and their intricate needs so we can help them."
For more information
Ainsworth AJ, et al. Fertility preservation for transgender individuals. Mayo Clinic Proceedings. 2020;95:784.
Refer a patient to Mayo Clinic.