Medical Disclaimer: This article is for informational purposes only and does not constitute medical advice. Fertility preservation decisions are highly individual. Please consult a board-certified reproductive endocrinologist who has experience working with transgender and gender-diverse patients.
For many transgender and non-binary individuals, the possibility of having biological children is deeply meaningful — yet fertility is rarely discussed at the time of gender-affirming care decisions. Gender-affirming hormone therapy (HRT) and surgeries can significantly affect or permanently eliminate reproductive capacity. Fertility preservation — banking eggs, embryos, or sperm before starting treatment — gives people options they can use years later, regardless of how their family plans evolve.
This guide covers what you need to know, drawing on the WPATH Standards of Care, Version 8 (2022) and guidance from the American Society for Reproductive Medicine (ASRM).
Why Fertility Preservation Matters Before Gender-Affirming Care
The WPATH Standards of Care v8 explicitly state that healthcare providers should discuss fertility preservation with all transgender and gender-diverse individuals before initiating hormone therapy or surgery — not after. This is because many of the effects on fertility are time-sensitive or irreversible.
Estrogen-based feminizing HRT progressively impairs sperm production; prolonged use may render sperm banking impossible. Testosterone-based masculinizing HRT can suppress ovulation and alter egg quality; while some studies suggest ovarian function may partially recover after stopping testosterone, it is not guaranteed. Surgical interventions — orchiectomy, vaginoplasty, oophorectomy, hysterectomy — permanently remove reproductive organs.
The ASRM Ethics Committee has affirmed that fertility preservation counseling for transgender patients is ethically appropriate and standard of care. Many individuals report that fertility was not discussed before they began hormones. If that applies to you, it is not too late to have this conversation with a reproductive endocrinologist — the key is acting while options are still available.
Options for Transgender Women and Transfeminine Individuals
Sperm Banking Before HRT
For transgender women and transfeminine individuals who have not yet started estrogen therapy, sperm banking is the most straightforward and well-established preservation option. A semen sample is collected, processed, and cryopreserved at a licensed facility. Cryopreserved sperm can remain viable for decades.
Timing matters significantly. Feminizing HRT — particularly estradiol — suppresses gonadotropin secretion from the pituitary, reducing sperm production. Studies have documented that semen parameters begin declining within months of starting estrogen, and some individuals develop azoospermia (no detectable sperm) within 6–12 months. The decline is variable but often difficult to predict in advance. Banking before initiating HRT consistently yields better sperm quality and quantity than banking after.
If HRT has already been started, banking is still worth attempting — especially if HRT was initiated recently. A reproductive urologist or endocrinologist can evaluate whether viable sperm are still present. In some cases, a temporary pause in HRT (in consultation with the patient's gender-affirming care provider) may allow partial recovery of semen parameters.
Success rates with banked sperm depend on whether they are used for intrauterine insemination (IUI) or IVF with ICSI. With ICSI, even low numbers of viable sperm can achieve fertilization. For context, IUI with donor sperm achieves approximately 10–20% per-cycle pregnancy rates; IVF with ICSI achieves significantly higher rates depending on partner age and egg quality.
Cost: Sperm banking typically costs $300–$1,000 for initial collection and processing, plus $300–$600 per year for storage.
Options for Transgender Men and Transmasculine Individuals
Egg and Embryo Freezing Before Testosterone Therapy
For transgender men and transmasculine individuals who have not yet started testosterone, egg freezing (oocyte cryopreservation) or embryo freezing (if a sperm source is available) are the primary preservation options.
Egg freezing requires a controlled ovarian stimulation cycle: injectable hormones (FSH and LH) are used to grow multiple follicles simultaneously, a process that takes approximately 10–14 days. The eggs are then retrieved under light sedation via transvaginal ultrasound-guided aspiration and frozen using vitrification (fast-freeze technology). This process does not require any physical changes to be paused or reversed — it is performed before HRT begins.
Fertility after testosterone therapy is an area of ongoing research. Testosterone suppresses ovulation and menstruation, but it is not a reliable contraceptive, and some transgender men have conceived during testosterone therapy. However, studies suggest that egg quality and ovarian reserve may be affected by prolonged testosterone use. The WPATH SOC v8 recommends discussing egg freezing before testosterone for individuals who wish to preserve reproductive options, precisely because the long-term impact on fertility is not fully characterized.
Transmasculine individuals who wish to carry a pregnancy can use frozen eggs or embryos in a future pregnancy, though this requires a functioning uterus. Those who have had a hysterectomy can use a gestational surrogate (see below).
Timing note: Some clinicians recommend a brief pause in testosterone before starting ovarian stimulation — typically 2–3 months — to allow the ovaries to respond optimally to stimulation medications. This decision should be made collaboratively with the patient's gender-affirming care provider.
Non-Binary and Intersex Considerations
Non-binary individuals may be pursuing any combination of hormonal and/or surgical interventions. The same principles apply: fertility preservation is best discussed and acted upon before any intervention that could affect reproductive capacity.
For intersex individuals, reproductive anatomy varies widely depending on the specific condition. Some intersex individuals have functional gonads capable of producing eggs or sperm; others do not. An evaluation by a reproductive endocrinologist familiar with intersex conditions is essential to understand what options may be available.
The WPATH SOC v8 affirms that the full spectrum of gender-diverse identities — including non-binary and intersex — should receive individualized, respectful reproductive counseling without pressure toward or against any particular decision.
Working with an REI — What to Expect
A reproductive endocrinologist (REI) is the specialist best equipped to guide fertility preservation in this context. When you contact a fertility clinic, it is worth asking directly whether they have experience working with transgender patients — protocols, language, and sensitivity vary by clinic.
At your first consultation, expect:
- A review of your gender-affirming care timeline — current or planned HRT, surgical plans
- Baseline fertility testing — for transmasculine patients: AMH, antral follicle count, and hormone levels to assess ovarian reserve; for transfeminine patients: semen analysis if HRT has already started
- A discussion of options, costs, and timelines — including whether a testosterone pause is recommended before egg retrieval, or whether brief HRT cessation is feasible for sperm banking
- Informed consent including discussion of psychological considerations and the open-ended nature of banked material
Most REI appointments are straightforward medical consultations. You do not need a referral from a gender-affirming care provider, though coordination between providers is ideal.
Finding LGBTQ+-Affirming Fertility Clinics
Not all fertility clinics have equal experience with transgender patients. When researching clinics, look for:
- Explicitly inclusive intake forms (gender-neutral language, space for preferred name and pronouns)
- Staff training in gender-affirming care
- A track record of working with LGBTQ+ patients
- Clear policies on storage, legal parentage, and use of banked material by a future partner or surrogate
Our fertility clinics near me directory includes clinics across the U.S. Many clinics affiliated with academic medical centers or large reproductive medicine groups have established LGBTQ+ programs.
Related Resources
- LGBTQ+ Fertility — Complete Resource Hub
- Egg Freezing — What to Expect, Costs, and Success Rates
- Home Insemination for LGBTQ+ Couples
- Find an LGBTQ+-Affirming Fertility Clinic Near You
Sources: WPATH Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (2022); ASRM Ethics Committee Report: Access to fertility services by transgender and nonbinary persons (2021); Adeleye et al., Fertility and Sterility 2019 (ovarian stimulation outcomes in transgender men); Payer et al., Journal of Clinical Endocrinology 2021 (sperm banking in transgender women); Light et al., Obstetrics & Gynecology 2014 (pregnancy in transgender men).
