One of the most significant and often overlooked aspects of gender-affirming medical care is its effect on fertility. Hormone therapy and gender-affirming surgeries can permanently or temporarily affect the ability to produce eggs or sperm. For transgender and non-binary individuals who may want biological children in the future, fertility preservation before transition is an important — and time-sensitive — consideration.
Hormone therapy effects on fertility differ by direction of transition. For transgender women (MTF) beginning oestrogen and anti-androgen therapy, sperm production typically declines and may cease entirely, though the timeline and reversibility vary by individual. For transgender men (FTM) beginning testosterone therapy, ovulation suppresses, though the underlying follicular reserve may be preserved. In both cases, fertility may not fully return after stopping hormones.
The window for fertility preservation is ideally before any hormone therapy begins, though preservation is sometimes possible after starting hormones if treatment is temporarily paused. Transgender women can bank sperm relatively simply and inexpensively through a sperm bank. Transgender men face a more complex process: to freeze eggs or embryos, they must either defer testosterone or pause it temporarily for an egg freezing cycle.
For transgender men who have not yet started testosterone, egg freezing follows the same process as for any person assigned female at birth: ovarian stimulation followed by egg retrieval and vitrification. The process takes approximately two weeks and may feel distressing for some individuals due to the required focus on reproductive anatomy that conflicts with gender identity. Many clinics now have specific protocols to minimise dysphoria during this process.
For those who have already started testosterone, pausing it for an egg freezing cycle is medically possible but emotionally and practically complex. The pause typically lasts 6-12 weeks. It may cause the return of menstruation, breast sensitivity, and other changes that can be distressing. Some reproductive specialists work specifically with transgender patients and have experience supporting them through this process.
Gender-affirming surgeries have more definitive effects. Orchiectomy (removal of testes) ends sperm production permanently. Hysterectomy and oophorectomy end egg production permanently. These are irreversible, which is why fertility preservation counselling before any surgical procedure is considered standard of care in most developed health systems — though in practice it is not always offered proactively.
Financial and logistical barriers to fertility preservation are significant for transgender individuals. In many countries, fertility preservation is not covered by public health insurance for this indication. Costs can be substantial: egg freezing cycles run from 1,500 to 4,000 euros plus medications; sperm banking is more affordable at 200-500 euros for the collection plus annual storage. Advocacy organisations and some clinics offer financial assistance programmes.
Legal considerations vary by country. In some jurisdictions, legal gender change requires sterilisation — a rule that has been challenged and overturned in many European countries following rulings by the European Court of Human Rights. In countries where this requirement has been removed, it is possible to preserve fertility, legally change gender, and have biological children as one's affirmed gender.
Sperm banking for transgender women who later use a surrogate or co-parent, and egg banking for transgender men who later carry a pregnancy themselves or use a surrogate, are both paths that have been successfully realised. There is growing clinical experience and research supporting the safety and success of these approaches.
The most important message for transgender and non-binary individuals considering transition is this: have the conversation about fertility early — ideally before any hormones or surgery. It does not commit you to having children. It keeps the option open. Many people do not regret fertility preservation even if they ultimately do not use it; many do regret not having preserved when the window was available.
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