Diane Chen and her colleagues at Lurie Children's Hospital in Chicago published a study in the Journal of Adolescent Health showing that among transgender adolescents and young adults who started hormone therapy, only about 20% received full fertility preservation counseling before treatment began — even though most international medical protocols formally require that conversation. The gap between recommendation and practice here isn't accidental: the decision to transition is often made at a moment when delaying the start of hormone therapy feels unbearable, and the question of future children feels distant and abstract.
Yet the effects of hormone therapy and gender-affirming surgery on reproductive function are partly irreversible, and decisions made — or not made — at the start of transition shape reproductive options for decades to come. This conversation is worth having not because having children should be a priority for every transgender person, but because the choice to preserve or not preserve fertility should be a deliberate one, not a consequence of running out of time to think it through.
The Standards of Care from the World Professional Association for Transgender Health (WPATH), the most authoritative international protocol in this field, explicitly require that fertility preservation options be discussed before starting hormone therapy, and especially before gonadectomy (removal of the ovaries or testes) — an irreversible procedure after which preserving fertility using one's own gametes becomes impossible.
This requirement exists precisely because the effects of hormone therapy on fertility aren't fully understood and aren't always reversible, while the consequences of surgery are unambiguously permanent. The standard doesn't assume every transgender person should be thinking about future children — it assumes everyone should have the chance to make an informed choice while that choice is still available.
Testosterone therapy usually suppresses ovulation and eventually stops menstruation, but this isn't reliable contraception: pregnancies have been documented in people taking testosterone, and testosterone itself is teratogenic — meaning it can harm fetal development in an unplanned pregnancy. The long-term effect of testosterone on ovarian reserve is only partly understood: available data suggest that ovarian function partially returns for many people after stopping testosterone, but this isn't guaranteed, especially after many years of use, and data on the very longest durations of use remain limited.
For those who want to preserve the possibility of genetic relatedness to a future child, two main paths are available: freezing oocytes (eggs) or freezing ovarian tissue — both ideally done before starting testosterone therapy, or after a temporary pause in taking it, which can itself be a source of significant discomfort if someone has already started therapy and doesn't want to interrupt it.
Estrogen therapy and anti-androgens gradually reduce sperm production, and over time spermatogenesis can stop entirely. Unlike the effects of testosterone on ovarian function, the impact of long-term estrogen therapy on spermatogenesis has been studied somewhat more thoroughly, but here too the degree and reversibility of change are individual and can't be precisely predicted for any given person.
Sperm cryopreservation — a considerably less invasive and less expensive procedure than egg freezing — is recommended before starting estrogen therapy or, if therapy has already begun, as early as possible, since with every additional month on the medication, the quality and quantity of sperm suitable for freezing can decline.
For transgender adolescents starting treatment with GnRH agonists (puberty blockers) before puberty is complete, the situation is fundamentally different: if the blockers are followed directly by gender-affirming hormone therapy, with no pause for gamete maturation to complete naturally, the person may never develop mature eggs or sperm suitable for standard cryopreservation.
This creates a particularly difficult dilemma tied to age: the adolescent and their family must decide about fertility preservation before puberty has even begun, or has progressed only slightly — that is, before the adolescent themselves may have a formed understanding of their own reproductive wishes. Experimental methods for preserving immature reproductive tissue in prepubertal children exist, but remain a subject of research rather than routine clinical practice with proven effectiveness.
Fertility preservation procedures themselves can be a source of gender dysphoria, creating a unique psychological burden absent for most other people preserving fertility (for example, before cancer treatment). Transmasculine people may need a transvaginal ultrasound and egg retrieval — procedures directly involving body parts associated with dysphoria. Transfeminine people may need to provide a semen sample in a way associated with masculinity they're working to distance themselves from.
Reproductive psychology specialists who work with transgender patients recommend neither treating this dysphoria as automatic grounds to skip fertility preservation, nor ignoring it: discussing specific protocols adapted to the patient's needs can significantly reduce the psychological burden without compromising the medical outcome. Callen-Lorde Community Health Center in New York, one of the first US clinics to build a fertility preservation program specifically for transgender patients, adapted the standard egg-retrieval protocol accordingly: patients are offered deeper sedation to avoid conscious awareness of the transvaginal part of the procedure, along with staff trained in gender-affirming communication at every stage of the visit.
The gap between standards-based recommendations and actual practice isn't explained by a single cause, but by a combination of factors. The financial factor is perhaps the most obvious: egg cryopreservation costs considerably more than sperm cryopreservation, and insurance coverage for these procedures remains rare for transgender patients even in countries with well-developed health insurance systems — partly because many policies classify fertility preservation as an "elective" procedure rather than a medically necessary part of gender-affirming care.
A second factor is time: people who have waited years for the chance to start hormone therapy often experience an additional delay for fertility counseling as a disproportionately heavy cost, especially if the psychological burden of dysphoria is already high. A third factor is information: research shows that a significant share of general practitioners, and even some gender-affirming care specialists, lack sufficient knowledge of the reproductive effects of hormone therapy to give patients a complete picture before starting treatment.
One of the few systematic studies on this topic was conducted in 2014 by gynecologist Alexis Light and colleagues, who surveyed 41 transgender men who had been pregnant after beginning transition. Almost all participants had stopped taking testosterone by the time of conception, and for most, the menstrual cycle resumed within a few months of stopping the medication — but not for everyone, and not on a predictable timeline, confirming that a quick, guaranteed return of the cycle can't be relied on.
For transmasculine people who want to conceive and carry a pregnancy themselves, the key practical point is the need to pause testosterone during conception and pregnancy, since testosterone has a proven teratogenic effect and can harm fetal development. Timing is especially important given a limited window — for example, tied to age or egg reserve — because it's impossible to predict in advance exactly how many months after stopping testosterone ovulation will resume for a specific person.
The psychological side of this decision deserves separate attention: temporarily stopping testosterone can mean the temporary return of physical characteristics associated with dysphoria, and pregnancy itself — a process deeply tied in cultural perception to femininity — can create additional psychological strain regardless of how wanted the future child is. In Light's study, some participants directly described the mismatch between a pregnant body and their own gender identity as harder to bear than the physical aspects of pregnancy itself. Specialists recommend building a plan for psychological support for the entire period in advance, before stopping therapy, rather than addressing it after the fact.
Below is the minimum set of questions that reproductive medicine specialists recommend discussing before starting hormone therapy or surgery, regardless of whether the question of future children feels relevant right now.
We deliberately limit ourselves here to general patterns rather than recommendations for a specific situation. Questions about preserving fertility before or during hormone therapy are a reason to consult a reproductive endocrinologist, ideally one experienced with transgender patients. Questions about psychological preparation for fertility preservation procedures are a reason to consult a psychologist specializing in gender-affirming and reproductive care. We don't replace either of these: our goal is to help you formulate the right questions for the right specialist, before rather than after irreversible decisions are made.
The conversation about fertility preservation during transition isn't a conversation about whether a transgender person should want children. It's a conversation about the right to an informed choice before part of one's reproductive options is lost irreversibly. International standards require that this conversation happen in advance, but in practice it happens far less often than it should — partly due to time pressure and haste, partly due to insufficient awareness among medical specialists themselves.
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