Fertility Options for Trans and Non-Binary People

Why this decision arrives at the wrong time

The HFEA opens its guidance for trans and non-binary people with an acknowledgement worth repeating: fertility may be the last thing on your mind when you are experiencing the distress of having a body that does not express your identity, and understandably some people want to start hormone therapy or have surgery as quickly as possible. Its point is not that you should delay, but that people sometimes find it a source of regret to have treatment without preserving fertility and to realise later that a biological family is not possible or is harder.

What follows is information, not a recommendation about what you should want. Deciding not to preserve fertility is a legitimate decision, and it is easier to make well if you know what it forecloses.

What hormone therapy and surgery do

The HFEA states that hormone therapy, whether oestrogen or testosterone, suppresses fertility and over time can lead to complete loss of it. Some people who stop hormone therapy will have fertility restored, but this is by no means guaranteed, and generally the longer the therapy, the more likely the effect is permanent.

Genital reconstructive surgery is different in kind. The HFEA is clear that it prevents having biological children without a surrogate or interventional fertility treatment, and that you cannot have children using your own sperm, eggs or embryos after such surgery unless you stored them beforehand. The relevant operations include removal of the fallopian tubes and ovaries, hysterectomy, removal of the testes, and penectomy.

One practical warning the HFEA gives that is easy to miss: hormone therapies are not an effective form of contraception.

Before starting hormone therapy

If you have been through puberty and have not started hormone therapy, freezing eggs or sperm is usually possible.

Egg freezing involves taking fertility drugs to stimulate the ovaries, then collecting eggs in a surgical procedure under sedation. The HFEA describes it as mostly very safe, with a risk of ovarian hyperstimulation which can require hospital treatment and in very rare cases can be fatal. For many trans men and non-binary people the difficulty is not the risk but the process itself, which involves internal scanning and oestrogen-driven changes over a period of weeks. Clinics vary in how well they handle that, and it is a reasonable thing to ask about when choosing one.

Sperm freezing involves producing a sample by masturbation or vibratory stimulation. Where that is not something you feel able to do, the HFEA notes sperm can be extracted surgically instead, though that is a more invasive procedure.

Before puberty

If you have not been through puberty and want to start hormone therapy or puberty-suppressing medication as soon as possible, it may be possible to store ovarian or testicular tissue, collected surgically.

The HFEA is careful about how it describes these options, and the caution is warranted. These treatments are experimental. There have been only a very small number of live births worldwide following replacement of ovarian tissue, and it is unclear at present how stored testicular tissue would be used to restore fertility — this has not been achieved. Very few clinics offer these procedures, so travel may be needed.

If you have already started

You still have options, though they involve a decision that many people find difficult. The HFEA states that a fertility specialist will probably recommend stopping your medication to increase the chance of a family through assisted reproduction, so that ovaries may start to ovulate again or the body may start producing sperm, generally over a few months.

It also acknowledges that some people find coming off hormone therapy distressing and may consider other routes, including using donated sperm or eggs, or adoption. It describes donor conception as a safe and increasingly common way of creating a family when done in the right way.

If you have been on hormone therapy and stop in order to store sperm, the HFEA notes the sperm quality may not be as good as it would otherwise have been.

At the point of surgery

If you are ready for genital reconstructive surgery, the HFEA notes it may be possible for your surgeon to collect ovarian tissue, or to collect sperm surgically, for storage. It sets out the current limitation on ovarian tissue honestly: the only way it can be used at present is by replacing it back into you. It cannot be put into another person, and eggs cannot currently be grown from it in a laboratory.

Storage: the rule that catches people

UK law permits storage of eggs, sperm or embryos for any period up to 55 years from the date they were first stored. But storage only continues lawfully if you renew your consent every 10 years, on the relevant consent form. If you do not renew, they are removed from storage and disposed of.

That makes contact details a substantive obligation. Your clinic must be able to reach you when renewal is due, and the HFEA warns that if it cannot, your stored material is at risk of disposal. Tell your clinic if you move, change your name, change your email or phone number, or separate from a named partner. Embryos additionally require the consent of both gamete providers to be stored at all.

Legal parenthood

UK law on this has not kept pace with practice, and it is better to know now than to discover it on a birth registration form. The HFEA states that the law specifically provides that the person who gives birth is the legal mother, with no exception for people who give birth and are not women, including trans men and non-binary people.

Where donated sperm or embryos are used and you are not married or in a civil partnership, both partners must complete HFEA consent forms before treatment for the non-carrying partner to be a legal parent. These cannot be completed afterwards. The HFEA suggests speaking to your clinic about legal parenthood questions specifically, and taking copies of every completed form.

Tests you will be asked to have

Before eggs, sperm or embryos are frozen you will be screened by blood test for infectious diseases and, where relevant, genetic conditions — typically HIV, hepatitis B and C, and HTLV I and II. If you may later want your embryos used in someone else's treatment, for example in a surrogacy arrangement, the screening rules for donation apply and further tests are required, including cystic fibrosis, chromosome analysis, cytomegalovirus, syphilis and gonorrhoea, plus blood grouping. The HFEA advises discussing surrogacy with your clinic before storage if it is a possibility, because the screening has to happen at the right point.