Fertility Preservation for Transwomen
Planning for Sperm Cryopreservation
With increasing visibility and acceptance of gender diversity, transgender patients are often seeking gender affirming treatments, such as hormone therapy and surgery, at younger ages. These treatments can impair reproductive potential and it is, therefore, imperative that this population is offered fertility preservation options and that these treatments are accessible and affordable. Many transgender patients would like to maintain the option for genetic children in the future, but too few are pursuing fertility preservation due a lack of information and access. With increasing awareness and research going into this field, the hope is that all trans patients, as well as their guardians in the case of trans youth, are counseled on and offered fertility preservation prior to initiation of gender affirming treatment.
In transwomen the mainstay of fertility preservation is sperm cryopreservation. Ideally, sperm freezing can be done prior to initiation of estrogen therapy, however, sperm freezing after initiation of hormone therapy is certainly an option as well. In trans youth a medication called Lupron is frequently used to delay the initiation of puberty in order to optimally plan for the initiation of gender affirming hormone therapy, including estrogen therapy. Lupron will shut down the signaling from the brain to the genitals and inhibit the initiation of sperm production. The effects of Lupron are reversible and it is important to discuss the option of fertility preservation with your healthcare provider prior to the planned pubertal transition from Lupron onto estrogen therapy in order to optimally time sperm freezing.
Estrogen therapy has been shown to negatively affect sperm parameters and the optimal time off hormone therapy prior to sperm freezing, if any, is currently an active area of study. This is why it is so important to educate this population on fertility preservation prior to starting hormone therapy. However, you can still preserve your fertility after starting gender affirming hormone therapy. Information regarding the time needed off estrogen therapy in order to freeze sperm continues to evolve. Many practices recommend at least 3 months off hormone therapy to optimize the sperm parameters and this is something you should discuss with your medical provider in order to make a decision that is right for you.
A critical point to consider is how many vials of sperm should be frozen before undergoing medical or surgical gender affirming treatment, which can lead to irreversible loss of fertility going forward. The sperm sample should be split up into multiple vials prior to freezing so that they can be thawed one at a time while the remaining vials remain frozen for future use. At the time of freezing, a semen analysis should be done so that you know how many total sperm are available and how many are present in each frozen vial. The frozen sperm can be used to create a pregnancy through insemination or in vitro fertilization. In the insemination process, the sperm is typically injected into a uterus at the time of ovulation with the hope that the sperm and egg will meet and create a healthy embryo that implants into the uterus. It is recommended to have at least 10 million moving sperm in a sample in order to proceed with intrauterine insemination (IUI) due to inherent inefficiencies in this procedure.
If your baseline sperm counts are low or you know you will need donor egg and/or a gestational carrier down the line, then you will need to use in vitro fertilization (IVF) to create embryos. In this case you need only 1 sperm per egg and can create embryos with greater efficiency. In the case of IVF, you need fewer sperm frozen up front as each cycle can often create multiple embryos with high potential for live birth and relatively few sperm. Ultimately the decision of how many vials of sperm to freeze is personal and should be discussed with your medical provider as well as a reproductive specialist. If you plan to attempt IUIs then you should consider freezing a higher number of vials. If there are few vials left after attempting IUI cycles then you should consider IVF in order maximize the potential of the sperm that is left.
Navigating the Emotions of Sperm Cryopreservation
The journey of transitioning from male to female is an immense undertaking and combines significant medical and psychological input. Our commitment to support this process is profound and primarily focused on presenting the prospect and actualizing future fertility preservation. For some, this is critically important and sought out while for others the present overwhelming challenge of transitioning diminishes the comprehensive evaluation of long-term possibilities for family building. Unfortunately, our experience with proactive fertility preservation in the oncology arena reveals that unless a supportive and accessible approach is established, sperm cryopreservation is often bypassed with enormous long-term consequences unleashed. It is for this reason that offering the possibility of future family building be offered in the best interest of the transitioning person so that they will have this option.
The action of providing a semen sample for cryopreservation for some is unsettling and a supportive, minimally intrusive, and accommodating setting is paramount. These days, web-based services are available that enable home collection and samples can be couriered for cryopreservation. At RMA of New York we have worked closely with numerous transitioning patients who are challenged with being able to produce an ejaculate. We offer counseling as well as interventions, including vibratory stimulation devices and electroejaculation procedures, to achieve the goal of fertility preservation. It is also paramount to educate those considering fertility preservation that this should be performed prior to initiating hormonal therapies which significantly impede sperm production.
When a sperm sample is provided it is assessed for quality using parameters such as concentration, motility, and morphology which then determine how many individual vials can be frozen for potential future use. It is ideally recommended that multiple samples be preserved to ensure optimal future fertility preservation. The capabilities using assisted reproductive technologies are profound, enabling a single sperm to be injected into an individual oocyte, thus dramatically lowering the number of viable sperm required to develop embryos. It is also reassuring to appreciate that once these semen samples are frozen in nitrogen there is no expiration date.
The future is unknown and uncertain and we encourage this population to thoughtfully consider and, if they choose too, avail themselves of sperm cryopreservation in the present so that the opportunity for family building in the future is possible.