By Jacqui Tomlins · May 8, 2017
This blog is a follow up to ‘Marc: The story of a trans dad’ and provides details of the issues associated with fertility for trans people. There’s a lot of practical information here, but what I love most about this interview is what Dr Devine says at the end: ‘I want people to not think too much about the limitations, but to focus on what’s possible.’
This is the last of four blogs highlighting my new “Early Years Support Guide” produced in collaboration with Rainbow Families NSW.
In recent years there has been greater societal acceptance of gender diversity, but there is still a significant gap in the provision of services for trans and gender diverse people. Dr Bronwyn Devine explains the medical options for trans and gender diverse people wanting to have children, and explores some of the personal issues involved in that journey.
Dr Bronwyn Devine, Medical Director, Monash IVF Mosman
Can you tell us about your work with trans and gender diverse people?
In 2012, I attended the inaugural Australian Transgender, Gender Diverse and Sistergirl conference in Cairns. There were a lot of lectures on medical and surgical approaches to transitioning, but very little information about starting a family or fertility preservation.
At that time, I was working in Canberra and starting to see a few trans men for general health checks and Pap smears and I was approached by an interstate couple looking to extend their family. They already had one child using donor sperm conceived with Intrauterine Insemination (IUI) and were hoping to do IVF this time around. It was one of the most rewarding experiences of my professional life, caring for the couple and helping them have their second baby. I knew this was an area I wanted to work in and since then I have seen a number of gender diverse couples, single people and teens all looking to have children or discuss fertility preservation.
The World Professional Association for Transgender Health (WPATH) states that: Patients must be clearly informed regarding their reproductive options prior to initiation of gender affirming therapies, and further recommends making fertility preservation an established procedure for all persons seeking to transition. I now lecture quite extensively to other health professionals in the fertility space on options for gender diverse people, and I’m passionate about improving access to Assisted Reproductive Treatment services for this group.
Can trans and gender diverse people still have their own biological children?
Whether you identify as trans, genderfluid or non-binary you still have the option of having children of your own if that’s what you want. Many trans people will be able to preserve their fertility before undergoing medical and/or surgical options to assist their affirmation. There are, however, a number of options available if you didn’t have the chance to arrange freezing of eggs or sperm prior to starting puberty blockers, hormones or undergoing surgery.
Having children may raise all sorts of issues for you and it’s important to talk though the emotional and psychologically aspects of trying to conceive, or of carrying a baby. A well-informed and supportive medical team can make a huge difference to this and it’s worth taking the time to seek out health professionals with expertise in this area.
What are the options for trans-men?
If you still have a uterus and ovaries
It is possible to produce healthy eggs even after you have started testosterone, or if you have been on it for a number of years. All ovaries run out of eggs eventually (menopause) but taking testosterone doesn’t seem to affect this process in any negative way. You have to take a break from the testosterone for a period of time to stimulate the ovaries to produce eggs. When testosterone levels drop people can sometimes feel anxious, tired or out of sorts and you may also experience a reduced libido. This can all be quite challenging for some people and you need to talk it though with your specialist.
If you are having eggs collected you’ll need to have injections which increase your oestrogen. After the eggs are collected, you get an increase in progesterone – the hormone responsible for pre-menstrual tension (PMT) – so you mayfeel tired, irritable and moody. Two weeks after egg collection, you will likely have a period which can also be very challenging. If you are not intending to carry the baby, you can resume testosterone pretty soon after the egg collection. Once you have eggs, they can be frozen or used to create an embryo with a male partner’s or donor‘s sperm. That embryo can be carried by a surrogate or female partner.
If you still have your uterus and ovaries and are considering becoming pregnant yourself this is possible too, either with your partner’s or with donor sperm. Testosterone does not act as a contraceptive and a number of trans men have conceived spontaneously. You would need to come off testosterone prior to conception and then you could try to conceive naturally, or you could use intrauterine insemination or IVF using a partner’s or donor’s sperm. Again, there are important psychological issues you’d need address if you took this path.
If you no longer have a uterus and ovaries
If you have frozen eggs or embryos then you may be able to have a child that is genetically related to you with the help of either a surrogate or a partner. If your partner has a uterus, is in good health, and happy to go through a pregnancy, then they could carry the baby. If not, you would need to find a surrogate to carry the baby for you.
If you didn’t freeze eggs or embryos, you would need to look at options for using a donor egg and donor or a partner’s sperm. If your partner has healthy ovaries then eggs may be obtained from them and fertilised using donor sperm. Your partner or a surrogate could then carry the baby.
What are the options for trans women?
Trans women have the option of freezing sperm or testicular tissue, but this is usually only successful if it’s done prior to starting hormones. If you have cryopreserved sperm, then you have the option of creating an embryo with a partner’s or donor’s egg using intrauterine insemination or IVF, and a partner or surrogate carrying the pregnancy.
Sperm cryopreservation is simple and reliable, but some trans women may find it difficult to masturbate to produce a semen sample. Surgical sperm extraction can be an option in this situation, but the quality of the sperm sample may be poor. Some trans women find the concept of stored male gametes an unwelcome reminder of a gender incongruent past.
If you do not have cryopreserved sperm and you have a partner who has a uterus and is able to carry a pregnancy, then you can create an embryo using a donor egg or your partner’s egg, and donor sperm, and that embryo can be carried by your partner. Alternatively, if your partner has healthy eggs and wishes to be pregnant then your partner may have an intrauterine insemination cycle using donor sperm.
Do you have any general advice for trans and gender diverse people who may be thinking about having a family?
I think it’s really important to have a well-informed and supportive medical team. Yes, there are certainly challenges involved, but there are a number of options and being trans or gender diverse doesn’t mean you have to give up the dream of being a parent. Talk to someone who knows about this. Even if you’re not ready to start a family yet, you can find out what your options are, and what’s possible. I want people to not think too much about the limitation, but to focus on what’s possible. I have many lovely stories of delightful and complex ways pregnancy has been achieved and families created.
Thank you, Dr Devine