International Review of Psychiatry

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Fertility options in transgender people

Chloë De Roo, Kelly Tilleman, Guy T’Sjoen & Petra De Sutter

To cite this article: Chloë De Roo, Kelly Tilleman, Guy T’Sjoen & Petra De Sutter (2016)
Fertility options in transgender people, International Review of Psychiatry, 28:1, 112-119, DOI:
10.3109/09540261.2015.1084275

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Published online: 19 Nov 2015.

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INTERNATIONAL REVIEW OF PSYCHIATRY, 2016
VOL. 28, NO. 1, 112–119
http://dx.doi.org/10.3109/09540261.2015.1084275

REVIEW ARTICLE

Fertility options in transgender people

Chloë De Rooa, Kelly Tillemana, Guy T’Sjoenb and Petra De Suttera
a
Department of Reproductive Medicine, Ghent University Hospital, Ghent, Belgium; bDepartment of Endocrinology and Centre for
Sexology and Gender, Ghent University Hospital, Ghent, Belgium

ABSTRACT ARTICLE HISTORY

Hormonal and surgical treatments for transgender people have a devastating effect on the Received 25 June 2015
possibility for these patients to reproduce. Additionally, transgender people tend to start sex Revised 12 August 2015
reassignment treatment at a young age, when reproductive wishes are not yet clearly defined nor Accepted 13 August 2015
fulfilled. The most recent Standards of Care of the World Professional Association for Transgender Published online
Health recommend clearly informing patients regarding their future reproductive options prior to 18 November 2015
initiation of treatment. This review gives an overview of the current knowledge and state-of-the-art KEYWORDS
techniques in the field of fertility preservation for transgender people. Where genital reconstructive Cryopreservation, fertility,
surgery definitely results in sterility, hormone therapy on the other hand also has an important, but transgender, reproductive
partially reversible impact on fertility. The current fertility preservation options for trans men are wish
embryo cryopreservation, oocyte cryopreservation and ovarian tissue cryopreservation. For trans
women, sperm cryopreservation, surgical sperm extraction and testicular tissue cryopreservation
are possible. Although certain fertility preservation techniques could be applicable in a
standardized manner based on clear biological criteria, the technique that eventually will be
performed should be the preferred choice of the patient after extended explanation of all possible
options.

Introduction transgender people without children (Wierckx et al.,

Gender dysphoria refers to distress or discomfort caused
by the incongruence between a person’s sex assigned at
birth and the gender a person identifies him or herself
with (Coleman et al., 2012). Treatment options to
facilitate the social gender role transition and to live in
accordance with the gender experienced comprises both
hormone therapy and/or surgical interventions
(Coleman et al., 2012). Unfortunately, both these options
have a negative effect on fertility (Coleman et al., 2012;
T’Sjoen et al., 2013). Health care professionals should
address the consequences for future fertility with their
patients before treatments have started.
Although there are only few studies that have
investigated the desire of transgender people to have
children, they all conclude that approximately half of
trans women (male to female transgender persons) and
half of trans men (female to male transgender persons)
wish to have children (De Sutter et al., 2002; Wierckx
et al., 2012a; Wierckx et al., 2012b).
The relevance of this topic is also reflected in the fact
that transgender people with children score significantly
higher on mental health and vitality scores than
2012b). In transgender women, parenting was even
identified as a suicide protective factor (Hamada et al.,
2014). Apart from an apparent child wish, a small
majority of transgender men and transgender women
would actually have cryopreserved their gametes, or
would have seriously considered doing it, if the tech-
nique had been available (Wierckx et al., 2012b).
Especially lesbian and bisexual transgender women
were interested in using their own cryopreserved sperm
to fulfil a future child wish (Wierckx et al., 2012b).
Regardless of their personal desire, the majority of
transgender people clearly expressed the opinion that
fertility preservation techniques should be discussed and
offered (De Sutter et al., 2002). On the other hand it is
striking that some transgender people are willing to
sacrifice their fertility, since fertility preservation was
considered not important enough to postpone their
transition process (De Sutter et al., 2002) as most of
transgender people are in favour of a fast transition
(Wierckx et al., 2012a).
The World Professional Association for Transgender
Health (WPATH) Standards of Care recommend in their
seventh version to discuss fertility options with patients

CONTACT Chloë De Roo, MD chloe.deroo@ugent.be Department of Reproductive Medicine, University Hospital Ghent, De Pintelaan 185, 9000 Ghent,
Belgium
ß 2015 Taylor & Francis

prior to any treatment or medical intervention, especially
before genital reconstructive surgery (Coleman et al.,
2012). The impact of each treatment on fertility as well
as a possible fertility preservation option to maintain the
possibility of having future genetically related children
should be addressed. As fertility preservation and
transgender healthcare are rapidly evolving fields, this
review gives an overview of the current state-of-the-art of
fertility preservation options for transgender people.
Clustered around questions, this manuscript provides
the most recent insights on the effects of therapy on
fertility, fertility preservation options, success rates,
future use of stored gametes, and transgender parenting.
This review is of interest for all healthcare professionals
working with transgender people and could be used as a
tool in order to correctly inform their patients on the
possible fertility preservation options they have.
Methods
Relevant literature on fertility and fertility preservation
in transgender was searched on PubMed. The time
period ranged from an unlimited start date to 1 May
2015. To identify appropriate studies, the following
terms were used (listed alphabetically): assisted repro-
duction, cryopreservation, donor, ethics, fertility, freez-
ing, gender dysphoria, oocyte, ovary, preservation,
reproduction, sperm, transgender, transgender men,
transsexual, transgender women. Abstracts were used
to select key articles. Of the identified literature, the
reference and citation lists were screened to find other
related and important articles.
What is the effect of sex reassignment therapy
on fertility?
Genital reconstructive surgery in transgender
women
Penectomy and orchidectomy in transgender women
leads to irreversible sterility.
Cross-sex hormone treatment in transgender
women
Clinically, prolonged oestrogen treatment results in
reduction of the testicular volume (Payer et al., 1979).
Additionally, oestrogens have a suppressive effect on
sperm motility and density in a (cumulative) dose-
dependent manner (Payer et al., 1979). Hamada et al.
(2014) clearly demonstrated a poor semen quality in
transgender women following feminizing therapy. Their
results show a high incidence of oligozoospermia,
asthenozoospermia and teratozoospermia, related to
cross-sex hormone treatment in transgender women
INTERNATIONAL REVIEW OF PSYCHIATRY 113
(Hamada et al., 2014; Lubbert et al., 1992). If semen
samples of such poor quality are used, assisted repro-
duction techniques, such as in vitro fertilization (IVF) or
intracytoplasmic sperm injection (ICSI) are needed
(Ettner et al., 2007).
Payer et al. (1979) described the histological effects on
Leydig cells of treatment with oestrogens alone or with
medroxyprogesterone acetate in transgender women.
Three morphologies were distinguished: Leydig cells very
similar to untreated Leydig cells (type 1), the absence of
Leydig cells in the presence of cells with increased
microfilaments and abundant smooth endoplasmic
reticulum and lipid drops (type 2) and complete absence
of any cell type but with varying amounts of microfila-
ments and pigmentation (type 3) (Payer et al., 1979). The
persisting spermatogonia show the typical features of the
so-called pale type-A spermatogonia (Schulze, 1988).
Because of the low mitotic rate of these cells, the pale
type-A spermatogonia survive disturbances of the endo-
crine balance, as well as other noxious stimuli such as
radio- and chemotherapy (Schulze, 1988). Therefore,
these cells are regarded as the stem cells of the human
testis (Schulze, 1988).
These histological findings explain why feminizing
hormonal therapy induces hypo spermatogenesis, ultim-
ately leading to azoospermia (De Sutter, 2001). The
impact is – to a certain extent – heterogeneous possibly
due to different types of cross-sex hormone therapy
(Schneider et al., 2015) and is reversible upon cessation
of oestrogen therapy based on the presence of the
spermatogonial stem cells (Schulze, 1988).
Genital reconstructive surgery in
transgender men
Hysterectomy with bilateral oophorectomy leads to
irreversible sterility (De Sutter, 2001; Wierckx et al.,
2012b).
Cross-sex hormone treatment in transgender men
Masculinizing hormonal therapy will in most cases lead
to a reversible amenorrhea but ovarian follicles are not
depleted from the tissue (De Roo et al., 2014; Van Den
Broecke et al., 2001b). Increased androgen levels may
however adversely affect follicle growth, mostly affecting
the more matured follicle stages as these follicles are
surrounded by an androgen sensitive theca cell layer
(Caanen et al., 2015; De Roo et al., 2014; Pache et al.,
1991). Apparently, primordial follicles in cryopreserved
and xenotransplanted ovarian cortical tissue do not lose
their potential to resume growth and maturation (Van
den Broecke et al., 2001a).
114 DE ROO ET AL.

Table 1. Fertility preservation options in transgender men prior to a hysterectomy and bilateral oophorectomy procedure.
Technique
Embryo cryopreservation
Oocyte cryopreservation
Ovarian tissue cryopreservation
Description
Controlled ovarian stimulation for
oocyte retrieval and fertilization to
obtain embryos for
cryopreservation
Controlled ovarian stimulation to
obtain oocytes for cryopreservation
Surgical excision of ovarian tissue for
cryopreservation
Considerations
Established method
Controlled ovarian stimulation
Vaginal procedure
Post-pubertal
Partner or donor sperm
Established method
Controlled ovarian stimulation
Vaginal procedure
Post-pubertal
No partner required
Experimental
Pre- or post-pubertal
No controlled ovarian stimulation
Possible at moment of genital
reconstructive surgery
No partner required
Future use
Male partner:
Use of partner’s sperm prior to cryo-
preservation, needs a surrogate
mother
Female partner:
Fertilization by donor sperm prior to
cryopreservation, implantation into
the partner’s uterus
Male partner:
Use of partner’s sperm, needs a
recipient uterus (surrogate mother)
Female partner:
Fertilization by donor sperm,
implantation into the partner’s
uterus
Male partner:
In vitro maturation and use of part-
ner’s sperm, need of a recipient
uterus (surrogate mother) (not
possible at this stage)
Female partner:
In vitro maturation, fertilization by
donor sperm, implantation into the
partner’s uterus (not possible at
this stage)

A current debate is still ongoing whether or not
masculinizing therapy induces polycystic ovarian syn-
drome (PCOS) (Caanen et al., 2015; Grynberg et al., 2010;
Pache et al., 1991). Descriptive histology by Pache et al.
(1991) showed some evidence for altered morphology
induced by testosterone treatment comprising of enlarged
ovaries, collagenized ovarian cortex, theca interna hyper-
plasia and stromal hyperplasia (Pache et al., 1991; Spinder
et al., 1989). The idea that androgens induce high anti-
Müllerian hormone levels, which is a particular feature of
PCOS is, however, questionable (Caanen et al., 2015).
On the other hand, one must realize that hormonal
interventions for transitioning do not exclude possible
pregnancy in transgender men (Light et al., 2014; T’Sjoen
et al., 2013). This implies that exogenous testosterone is
not an adequate means of birth control. Testosterone has
teratogen effects on the fetus, therefore transgender men
should avoid pregnancy while on testosterone therapy. In
cases of non-surgery, contraception should be discussed.
Evidence regarding the choice of the correct contracep-
tive is currently lacking. We suggest progesterone-only
medication, a progesterone-releasing intra-uterine device
or barrier methods of birth control in order to avoid the
use of oestrogen treatment.
What are the current fertility preservation
options for transgender men?
Current fertility preservation options include cryo-
preservation of embryos, oocytes or ovarian tissue.
The theoretical options are presented in Table 1,
including a short description of every technique,
considerations in favour of and against the technique,
and the potential future use in the case of a male or a
female partner. These options are based on the known
fertility preservation options for patients undergoing
gonadotoxic treatment (such as chemotherapy) trans-
posed to the specific needs of transgender patients. It is
preferable to bank gametes before commencing cross-sex
hormone treatment. For transgender men and trans-
gender women already using cross-sex hormone treat-
ment, an interruption of hormone treatment is
recommended for 3 months to restore possible ther-
apy-induced effects.
Embryo cryopreservation
The embryo cryopreservation technique consists of
hormonal stimulation and oocyte aspiration for IVF/
ICSI techniques to create embryos that are subsequently
cryopreserved for future embryo transfer (Ettner et al.,
2007; Wallace et al., 2014). This is an appropriate option
for post-pubertal transgender men with a male partner
and offers the possibility of a genetically related child.
However, if desired, a sperm donor can also be used to
create embryos (Wallace et al., 2014). This fertility
preservation method requires a controlled ovarian
stimulation and thus female hormone exposure
(Wallace et al., 2014). Additionally, frequent vaginal
ultrasound monitoring is needed during the ovarian
stimulation phase and a transvaginal surgical procedure
is performed for oocyte aspiration (De Sutter, 2001;
Wallace et al., 2014). This can be a physical and
psychological burden for many transgender men,
 INTERNATIONAL REVIEW OF PSYCHIATRY 115

thereby limiting their future reproductive options
(Wierckx et al., 2012b). Although technically possible,
genital exams in transgender men may need to be
postponed until a trusted doctor-patient relationship is
established (Steever, 2014).
Nowadays embryo freezing is a routine procedure in
the field of assisted reproduction. In the case of an embryo
transfer, a recipient uterus (surrogacy mother) is required,
especially when the uterus has been removed upon genital
reconstructive surgery in transgender men (De Sutter,
2001; Ettner et al., 2007). In the case of a female partner,
partner donation – where an oocyte of the transgender
man is inseminated with donor sperm and subsequently
transferred to the female partner – is a possibility.
Oocyte cryopreservation
Oocyte cryopreservation includes hormonal stimulation
and oocyte retrieval for oocyte vitrification (Wallace
et al., 2014). Therefore the same considerations as for
controlled ovarian stimulation for embryo cryopreserva-
tion have to be taken into account. Cryopreservation of
oocytes does not require fertilization before cryopreser-
vation. Therefore there is no need for a partner or for the
use of donor sperm at the moment of the fertility
preservation procedure. Again it is an established
technique and future use of the cryopreserved oocytes
requires the use of partner sperm or donor sperm and a
recipient uterus which can be the female partner or a
surrogate if a male partner is present (De Sutter, 2001).
Ovarian tissue cryopreservation
Ovarian tissue cryopreservation is the resection and
cryopreservation of the ovary (Wallace et al., 2014).
The technique requires a surgical procedure but does not
include an ovarian stimulation. Since cross-sex hormone
treatment does not deplete the ovary, resection of the
tissue can be performed at the time of genital recon-
structive surgery (Van Den Broecke et al., 2001). At the
moment it is a promising but experimental procedure
(Wallace et al., 2014).
Future use of the frozen tissue can be either transplant-
ation of thawed tissue or in vitro maturation of primordial
follicles. Transplantation of ovarian cortical strips can,
however, include unwanted side effects by restoring female
hormone activity. It makes natural conception theoretic-
ally possible in cases where the uterus was not removed or
if this transplanted ovarian tissue is stimulated in order
to obtain mature oocytes for IVF/ICSI techniques. In vitro
maturation of primordial follicles (the abundant fol-
licle stage in ovarian cortex) would prevent the recovery
of female hormone activity after transplantation, but
in vitro maturation starting from these immature follicles
is not yet possible (Dewailly et al., 2014; Ettner et al., 2007;
Wierckx et al., 2012b). Like oocyte cryopreservation,
once a mature oocyte is obtained, the use of partner
sperm or donor sperm and a recipient uterus upon
thawing of the oocytes for future use (female partner or
surrogate mother) enables fertility treatment.
What are the current fertility preservation
options for transgender women?
The fertility preservation options for transgender women
include cryopreservation of sperm collected through
ejaculation or direct testicular extraction and cryopreser-
vation of immature testicular tissue. An overview is
provided in Table 2.

Table 2. Fertility preservation options in transgender women.

Technique
Sperm cryopreservation
Surgical sperm extraction
Immature testicular
tissue cryopreservation
IVF, in vitro fertilization; ICSI, intracytoplasmic sperm injection.
Description
Cryopreservation of ejaculated sperm
through masturbation or vibratory
stimulation
Percutaneous aspiration of sperm
from testis or epididymis
Surgical biopsy of testicular tissue
Considerations Future use
Established technique Male partner:
Masturbation Needs a donor oocyte and surrogate
Post-pubertal mother
Female partner:
Intra-uterine insemination or IVF/ICSI
depending on sperm quality followed
by embryo transfer in partner
Established technique Male partner:
No masturbation Needs a donor oocyte and surrogate
Surgical procedure mother
Post-pubertal Female partner:
IVF/ICSI treatment followed by embryo
transfer in partner
Experimental Male partner:
Pre- or post-pubertal In vitro maturation and need of a donor
Possible at moment of genital oocyte and surrogate mother (not
reconstructive surgery possible at this stage)
Female partner:
In vitro maturation and IVF/ICSI followed
by embryo transfer in partner (not
possible at this stage)
116 DE ROO ET AL.
Sperm cryopreservation
The cryopreservation of ejaculated sperm (through
masturbation or vibratory stimulation) is the simplest
and most reliable method of male fertility preservation
(Wallace et al., 2014). Transgender women may find it
difficult to masturbate in order to produce a semen
sample for preservation. Even the fact that they have
semen samples stored would remind them of their male
past and would therefore not make them feel as a
complete woman (De Sutter et al., 2002; Wierckx et al.,
2012a). Depending on the sperm quality, the cryopre-
served spermatozoa can be used for future intrauterine
insemination or to perform IVF/ICSI in the case of a
female partner (De Sutter, 2001). The need for IVF/ICSI,
however, creates the necessity to start controlled ovarian
stimulation in the female partner, followed by oocyte
aspiration. The embryo obtained can subsequently be
transferred into the partner’s uterus. In the case of a male
partner, a donor oocyte and a surrogate mother are both
necessary.
Surgical sperm extraction
In cases of surgical sperm extraction, a percutaneous
aspiration of sperm from the testis or the epididymis is
performed (Wallace et al., 2014). Again, this is an
established method in daily IVF practice. Although a
solution for transgender women for whom masturbation
is a burden, one must not forget that this is a surgical
procedure (Wallace et al., 2014). The obtained spermato-
zoa can be used for future IVF or ICSI procedures in the
case of a female partner. Again, in the case of a male
partner, an oocyte donor and surrogate mother are both
necessary in order to fulfil their child wish (Ettner et al.,
2007).
Testicular tissue cryopreservation
For cryopreservation of immature testicular sperm, a
surgical biopsy of testicular tissue from pre- or post-
pubertal transgender women is performed (Wallace
et al., 2014). This option overcomes the need for
masturbation and is possible in pre-pubertal boys
(Wallace et al., 2014). It is a surgical procedure that
can be combined with the genital reconstructive surgery.
Compared to the other two options, this is an experi-
mental method. For future use, an in vitro maturation
procedure or transplantation is necessary followed by
assisted reproduction techniques. Transplantation
can, however, restore the male endocrine environment,
which clearly is an undesired effect for transgender
women.
What would be the future fertility preservation
options for transgender patients?
Current research focuses on optimizing the in vitro
maturation of immature oocytes and spermatogonial
stem cells. An optimized culture model would allow the
use of the currently banked ovarian or testicular tissue
without the need for transplantation. This would solve
the unwanted side effect of endocrine restoration by the
transplanted tissue.
For transgender men, the in vitro maturation of
cumulus-enclosed oocytes collected during ovarian tissue
processing may be possible in the future. These oocytes
originate most probably from antral follicles punctured
through manipulation of the tissue during the cryo-
preservation procedure. In combination with freezing of
the ovarian cortex, cryopreservation of in vitro matured
oocytes might further broaden the reproductive perspec-
tives for transgender men.
Apart from a testicular biopsy in transgender women
to obtain spermatogonial stem cells, research to obtain
artificial gametes through stem cells is ongoing
(Duggal et al., 2014; Ettner et al., 2007). This would be
a possibility for those patients who cannot or have not
stored their own gametes and currently need oocyte or
sperm donation to fulfil their future genetically related
child wish (T’Sjoen et al., 2013).
After fertility preservation, what is the
possibility for transgender gestation?
In the USA, unlike in many European countries,
hysterectomy with oophorectomy are not necessary for
legal sex reassignment (T’Sjoen et al., 2013). Also, in
Sweden, the requirement of sterilization for sex reassign-
ment legalization was ruled unconstitutional in court in
2013. These changes affect clinical practice (Rodriguez-
Wallberg et al., 2014). In cases where transgender men
decide to retain their ovaries and uterus, they may regain
fertility after discontinuing androgen therapy. It is a fact
that transgender men are becoming pregnant and are
having babies, regardless of prior testosterone use (Light
et al., 2014). This also emphasizes the need for
specialized obstetric care, addressing the specific needs
of pregnant transgender men.
In transgender women, being pregnant and giving
birth is still impossible. The Swedish research unit of
Brännström and his colleagues conducted a series of
uterus transplants and reported a first live birth in 2014
(Brännström et al., 2015). This opens the possibility for
assisted gestation for transgender women (Murphy,
2014). However, there are important medical concerns
regarding uterus transplantation if introduced to

transgender people (Hamada et al., 2014; T’Sjoen et al.,
2013). A difficult surgical procedure would be needed in
order to change the anatomy of the male pelvis with the
intention to perform a successful uterus transplantation.
Moreover, immunosuppressive therapy would be neces-
sary and is possibly contra-indicated during a pregnancy
(T’Sjoen et al., 2013), but that by itself would not be any
different from a uterus transplantation in a cisgender
(being a non-trans) female patient.
What is known about transgender parenting
and children?
The above mentioned options clearly show the oppor-
tunities (and limits) for transgender patients with a
present or future genetically related child wish. All these
possibilities, however, are strictly regulated by national
legislations. Apart from legislation, some healthcare
professionals still need to be convinced about the
necessity and the ethical acceptability to preserve fertility
in this patient group (De Sutter, 2001). The underlying
question is whether transgender parenting has a negative
influence on the gender identity and the sexual orien-
tation of a child (T’Sjoen et al., 2013; White & Ettner,
2004). Few studies have addressed this question and
conclusive evidence is scarce. Although the results from
these studies are reassuring, long-term follow-up studies
are undoubtedly needed. None of the studies published
so far showed that children suffer to such an extent that
would warrant a prohibition of transgender parenting
(Murphy, 2012). Transgenderism as a reason to interrupt
contact between the transgender parent and his or her
children, as is the case in some countries, is documented
to be harmful for the children (Green, 1978; T’Sjoen
et al., 2013). It is shown that a child having a transgender
parent may experience more transient and mild harass-
ment than those who do not have a transgender parent
(Green, 1978; T’Sjoen et al., 2013).
Children who were younger at the time of their
parent’s transitioning, showed better adaptation and
maintained healthier relationships with both the transi-
tioning and the other parent in a study by White and
Ettner (2007). A less conflicted relationship between
child and parents is also predicted by a positive
relationship between the two parents (White & Ettner,
2004, 2007). In cases of transitioning of the transgender
parent before the birth of a child, it is important to
disclose the transgender identity of the parent early in
childhood, rather than later in the life of the child. The
possibility that certain specific circumstances concerning
the birth of the child are disclosed by someone else than
the parents should be avoided as this can be tremen-
dously traumatic for the child (Chiland et al., 2013)
INTERNATIONAL REVIEW OF PSYCHIATRY 117
Discuss ferlity and
refer to a
specialized centre
Assessment and Hormonal Sex reassignment
diagnosis treatment surgery
Discuss ferlity and
refer to a
specialized centre
Figure 1. Therapeutic approach.
Discussion and conclusion
Fertility and fertility preservation are important topics to
discuss before planning any treatment to facilitate a
transgender person to live according to the gender they
identify themselves with. An overview of when to
address fertility in the approach of transgender people
is given in Figure 1. A patient should be clearly informed
upon diagnosis, before starting hormonal treatment or
genital reconstructive surgery. The first information on
fertility preservation should be given by healthcare
professionals at the gender identity clinic service. Next,
the patient should be referred to a specialized fertility
centre to discuss in more detail his or her options.
Information on success rates of each technique especially
is highly patient-specific. In cases of sperm cryopreser-
vation or surgical sperm extraction, success rates are
similar to preservation in non-trans patients. However,
reproductive techniques (intrauterine insemination or
ICSI) as well as pregnancy results depend on the age and
fertility-related medical history of the partner. In cases of
embryo or oocyte cryopreservation, the age of the trans
men at the moment of cryopreservation is very import-
ant. All the other aforementioned techniques are still
experimental, therefore referring a patient to a specia-
lized fertility centre in order to have correct and nuanced
information is highly recommended.
The current available options for fertility preservation
are very promising. One must, however, realize that the
banking of gametes cannot guarantee future treatment. If
a trans person has a wish for a genetically related child
(individually or as a couple) pre- or post-transitioning,
they should undergo the screening procedure according
to the protocol of the centres for assisted reproduction.
Furthermore, not all theoretical reproductive options are
possible at this time and not all forms of medically
assisted reproduction are available in every country.
Additionally, medically assisted reproduction, although
considered to be safe, is not without health risks and it is
often expensive.
The use of the cryopreserved gametes will there-
fore depend on their quality, success rate of the
118 DE ROO ET AL.
technique, and choice of partner, aside from the centre’s
policy and national legislation. Fertility in transgender
patients also raises the need for appropriate and adapted
care before conception, during pregnancy, and after
giving birth.
We conclude that transgender patients should be
counselled on reproductive issues by professionals prior
to initiating treatment in order to have a clear overview
of the effects of treatment, the preservation possibilities,
and what to expect from it. We advise referring
transgender people to specialized centres for assisted
reproduction to discuss possibilities. Even though a
patient does not have a clear view on his or her future
child wish, it is very important that patients have access
to clear and detailed information so that a well informed
choice can be made.
Declaration of interest
We wish to acknowledge the Gender Identity Research and
Education Society (GIRES) foundation for their support in our
research. P.D.S. is holder of a fundamental clinical
research mandate from the FWO-Vlaanderen (FWO 05/
FKM/001). C.D.R., K.T., G.T. and P.D.S. contributed to
conception and design of the manuscript and drafting or
revising of the article. All authors approved the submitted
version. The authors alone are responsible for the content and
writing of the paper.
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