Where do trans families come from? While transgender parents are underrepresented in the media, we are very much a part of the culture. Our families may include one, two, or more parents and our children. Sometimes, these families conceive at home and without provider support. Others might use fertility assistance like intrauterine insemination (IUI) or in vitro fertilization (IVF). Other families might use an egg donor, sperm donor, or gestational carrier. Some families get started before one or both parents begins their gender transition. Others plan to have children after many years of gender-affirming hormone therapy (GAHT, sometimes called HRT). Some folks foster or adopt, become parents in a blended family constellation, or raise children who came to them in other ways.

All of these types of families are valid. While not every transgender person wants to become a parent or raise children, many of us do. This blog is for people who want to learn more about their family planning options and how pregnancy can work with GAHT.

Choosing to transition with gender-affirming hormones doesn’t mean you have to give up your plans to start a family. You can still plan your family when you plan to start hormones. Since gender-affirming hormones affect every system of the body, including the reproductive system, you will experience changes to your fertility. However, it isn’t an either-or situation. You do not have to choose between your mental health, gender journey, identity, and your future family. Your provider and care team are here to understand your goals, for now and for the future, and to help you understand your options and any side effects of medications you choose.

How estrogen/E+ medications change your fertility

All hormonal medications will affect your fertility over time. However, it’s not going to happen all at once. Only surgery, such as a vasectomy, orchiectomy, or other bottom surgery will result in immediate sterilization. People on estrogen/E+ medications will experience gradual fertility loss. This means that while someone is taking estrogen, their sperm count will decrease and potentially result in sterilization.

Dr. Maddie Deutsch, Associate Professor of Clinical Family & Community Medicine at the University of California – San Francisco (UCSF), and Medical Director for UCSF Transgender Care said, “It is best to assume that within a few months of starting hormone therapy you could permanently and irreversibly lose the ability to create sperm. Some people may maintain a sperm count on hormone therapy, or have their sperm count return after stopping hormone therapy, but it is best to assume that won’t be the case for you.”

However, this is not a hard and fast rule. There is scant data or research about the effect of estrogen on transgender people’s fertility. Trans women, nonbinary people, and transfeminine people all may use estrogen as gender-affirming medications. But the impact of feminizing hormone therapy on fertility is unclear. It is not possible to predict what each individual’s outcome will be.

Two recent studies suggest that transgender women who take estrogen, but still have their reproductive organs, do not lose their fertility absolutely or permanently. A study published in the journal Urology in 2019 showed that the majority (80 percent) of transgender women who participated in the study had germ cells (or cells that become sperm) present in the testicle, even after one year on estrogen. Spermatogenesis (or the ability to make sperm) was preserved in approximately 40 percent of these individuals. That means that even on hormonal therapy, many people were able to produce healthy sperm.

Another study, published in Andrology in 2021, showed that transgender women who had discontinued estrogen, presented with significantly lower total sperm count, lower sperm concentration, and lower sperm motility than individuals who were not using gender-affirming hormone therapy (GAHT). However, the sperm produced by transgender women in the study were healthy. Since we don’t have much published data on trans women and pregnancy, it’s hard to predict what someone’s outcome may be when starting estrogen. This is why Plume’s healthcare team counsels folks to take their time with starting hormones and gather all the information so they can make informed decisions. Seeing a specialist might feel like the right choice for you. While it is possible you will be able to start a family in the future without fertility support, it’s always better to be safe than sorry.

Because of the changes caused by estrogen, you might want to use a fertility preservation method to plan for your future family if using your genetic material to create a child is important to you, or may be in the future. Many people do this before beginning estrogen. If having biological kids is really important to you, saving your sperm before starting hormones will give you the best chance of success. Some people prefer to wait until they are ready, then decrease or stop their dosage of estrogen so that their fertility increases. It’s important to know that even in people who have stopped their estrogen for months, sperm counts don’t frequently return to normal (and frequently won’t be high enough to save sperm).

Sperm banking, or freezing sperm, is the most common type of fertility preservation. The process takes 2-4 weeks and frozen sperm may be used up to 15 years or more after it is stored. Discuss your options with a trusted medical provider, especially if you see parenthood in your future and want to preserve the option of using your sperm.

How testosterone can change your fertility

People on testosterone also experience fertility changes over time. Depending on your dose of testosterone, many people notice that their menstrual period stops within 3-6 months of consistently taking the full dose of testosterone. Within the first year, periods usually go away completely as the ovaries and uterus become dormant. If you are just starting T, you may notice that your periods become lighter, arrive later, or are shorter in duration. Some people notice that their periods are heavier or longer-lasting for a few cycles before they stop altogether.

Taking testosterone can make ovulation irregular and halt menstruation, but it does not necessarily lead to infertility. Instead, it makes the reproductive system go to sleep. Your reproductive organs are inactive, not inoperative. Any trans person who is sexually active and still has their reproductive organs—that is, the uterus, fallopian tubes, ovaries, and/or testes—can conceive.

For family planning, it’s important to work with your healthcare provider to talk about pregnancy. Testosterone is a teratogen, which means that it can cause birth defects or harm a developing fetus. This can endanger your pregnancy. If you do want to conceive and carry a pregnancy to term, you’ll have to stop testosterone treatment and wait until your provider tells you that it’s okay to begin trying to conceive. Usually, this means 3-6 months off T.

Dr. Deutsch said, “It’s also important to know that, depending on how long you’ve been on testosterone therapy, it may become difficult for your ovaries to release eggs, and you may need to consult with a fertility specialist and use special medications or techniques, such as in vitro fertilization, to become pregnant.”

Some trans men, transmasculine people, and nonbinary people who use T also use fertility preservation to save their eggs for a later pregnancy. Fertility preservation can be part of an IVF pregnancy as well. Donating and storing eggs is one way to save genetic material for future family planning.

A study published in the journal Obstetrics and Gynocology in 2014 showed that transgender men are able to conceive, carry a pregnancy, and have healthy deliveries. This cross sectional study of 41 transgender men who carried a pregnancy included 25 (61 percent) who had previously been on testosterone before trying to conceive; the majority (84 percent) of these transgender men who had been on T were able to use their own ovaries.

The path to fertility preservation can be challenging because of the medical interventions that are required for the process. Transvaginal ultrasound (TVS) and hormonal ovarian stimulation can have a negative impact on gender dysphoria for some people. A study published in Human Reproduction in 2017 showed that trans men and other transmasculine people benefit from gender-neutral or affirming language during fertility preservation. (If you’re looking for a provider who understands how to support trans people during pregnancy, the WPATH provider directory is a great place to start.) The study’s participants were able to lean on family and friends for emotional support and focus on the desired result of the process, in order to cope with the physical and psychological challenges of egg donation.

Can someone get pregnant while taking testosterone?

Not everyone on testosterone has sex with partners whose bodies produce sperm and semen. However, for folks who do, it’s important to use birth control if you are trying to prevent pregnancy. It is not enough to rely on testosterone or the cessation of menstrual cycles alone. It is a common misconception that testosterone will cause total infertility. Gender-affirming hormone therapy (sometimes also called HRT) is not a form of birth control,and it is possible to get pregnant while on T—even when you aren’t getting your period. Using hormones is not the same as birth control or sterilization. Assuming that hormone therapy will make you infertile might lead to an unplanned or unwanted pregnancy.

As long as you still have a uterus and ovaries, you can get pregnant. Infertility is not universal, immediate, or guaranteed in transgender people undergoing hormone therapy. Everyone’s body is different, so it is possible to conceive even at higher doses of GAHT. Transgender men, transmasculine people, or other folks who take T may use any form of contraception. There are options that do not contain estrogen, and some that contain no hormones at all. There are many contraception options that are long-acting and do not require taking a daily pill, such as Depo-Provera or an IUD. People taking testosterone as GAHT can safely use emergency contraception, also known as the “morning after pill.”

Unplanned pregnancy is stressful and can create dysphoric feelings. Rather than put your mental wellness at risk, plan ahead to prevent an unwanted pregnancy. If you are taking testosterone and sexually active with someone(s) with sperm, talk to your healthcare provider about your birth control options.

Planning your family as a trans person

All types of families and methods of family planning are valid. It’s not about what’s “right.” It’s about what’s right for you. Some people begin the fertility preservation process before they start hormone therapy. Other people taper off hormones so that they can initiate a pregnancy. Many fertility support options exist, depending on your needs and wishes for your future family. Family planning for transgender people can look like:

  • Conceiving without fertility assistance

  • Using IVF to get pregnant

  • Having a baby with donated eggs or sperm

  • Working with a gestational carrier

  • Preserving your eggs, sperm, embryos, or other tissue so you can start when you’re ready

  • Fostering and/or adoption

Using gender-affirming hormone therapy doesn’t mean you have to choose between starting your family and your gender journey. Choosing to transition does not automatically mean you have to close the door on conception, pregnancy, and parenthood. Many kinds of families exist—including families with transgender moms, dads, and parents.

There are lots of ways to start your own family and still take care of yourself. Living your best life doesn’t mean you need to compromise your dreams of being a parent and raising children of your own. If you’re thinking about your future fertility, need to discuss contraception, or have questions about how GAHT can affect your family plans, please reach out to our care team to discuss your options. Plume does not currently prescribe contraception, but we do have resources and referrals for both fertility preservation and birth control.