Fertility counseling important before transgender care

Contemporary OB/GYN JournalVol 68 No 10
Volume 68
Issue 10

In a recent study, transgender women had reduced sperm quality compared to cisgender men, and transgender men used contraception at similar rates to cisgender women.

Fertility counseling important before transgender care | Image Credit: © Pixel-Shot - © Pixel-Shot - stock.adobe.com.

Fertility counseling important before transgender care | Image Credit: © Pixel-Shot - © Pixel-Shot - stock.adobe.com.

According to a recent study, transgender individuals should receive counseling on fertility preservation before gender-affirming hormone therapy.

A discrepancy between an individual’s self-perceived gender and gender assigned at birth is described as gender incongruence or transgender, with self-perceived gender described through the terms trans man and trans woman. Being transgender is reported by 17 to 33 individuals per 100,000 inhabitants in Germany.


  • Counseling on fertility preservation is crucial before transgender individuals undergo gender-affirming hormone therapy, as this therapy can lead to infertility.
  • Transgender individuals often experience significant distress, which can increase the risks of depression and suicidal ideation, making comprehensive care essential.
  • Trans men undergoing gender-affirming hormone therapy may still experience natural conception, necessitating reliable contraception.
  • Research findings suggest that gender-affirming hormone therapy does not significantly impact the ovarian function in trans men, with normal findings reported in certain tests.
  • Fertility preservation measures, such as sperm or tissue cryopreservation, are essential for both trans men and trans women before they undergo gender-affirming hormone therapy to address potential infertility issues.

Transgender individuals often experience significant distress, increasing the risks of depression and suicidal ideation. Gender incongruence may be treated through hormone therapy or surgical intervention, improving the quality of life in transgender individuals.

Patients undergoing gender-affirming hormone therapy may experience natural conception, especially trans men who experience virilization of the embryo. These patients will often require reliable contraception.

As gender-affirming hormone therapy may lead to infertility, certain guidelines require the possibility of infertility be discussed with patients before treatment. Fertility may be preserved through cryopreservation of sperm or testicular tissue in trans women and embryos, oocytes, or ovarian tissue in trans men.

Investigators conducted a systematic review to highlight factors of contraception and fertility preservation in transgender individuals. Literature was retrieved between December 2021 and June 2022 through searches of Pubmed and Web of Science databases. 

Research articles in an English or German language published in peer-review journals were included. Studies were categorized based on topic, with relevant data being summarized in tables. 

There were 26 studies included, 4 discussing contraception in trans men, 6 fertility in trans men, 5 fertility preservation in trans men, and 12 fertility and fertility preservation in trans women. In 1 study on fertility preservation, both trans men and trans women were included.

Gender-affirming hormone therapy did notimpact the value of the anti-Müllerian hormone test or the antral follicle count in trans men. Normal findings were also reported for the distribution of follicles in the ovarian cortex of trans men who received adnexectomy.

Of the 32 trans men who received testosterone therapy, 1 had confirmed ovulation and 12 were questionable. Spotting or bleeding during the study was reported by 41% of participants.

Similar rates of contraception use were found between trans men and cisgender women, with use of vaginal contraceptives during the last vaginal intercourse reported by 79% of trans men. Both trans men and cis women experienced an increase in long-acting reversible contraceptive use over a 10-year period.

Trans men and cis women also did not significantly differ in the number of oocytes obtained for fertility preservation. Oocyte cryopreservation following pertinent counseling was reported in 26% of trans men.

In trans women, semen quality was significantly decreased even before gender-affirming hormone care, with azoospermia reported beforehand in 1.8% to 10.3% of patients. Sperm concentration and total sperm count were significantly reduced by gender-affirming hormone care. Fertility-preservation measures following counseling were reported by 75% of trans women.

These results indicated impaired fertility is common in trans women following gender-affirming hormone therapy, but that this type of therapy is not a reliable contraceptive method. Investigators concluded counseling about fertility preservation should be provided to transgender individuals before gender-affirming hormone therapy.


Feil K, Reiser E, Braun AS, Böttcher B, Toth B. Fertility, contraception, and fertility preservation in trans individuals. Dtsch Arztebl Int. 2023;120(14):243-250. doi:10.3238/arztebl.m2023.0026

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