There’s a lot to consider when starting a family as a trans person, from the way gender-affirming care intersects with fertility to the ins and outs of insurance coverage to ensuring parental rights. And while today’s political climate may make it feel scarier and more overwhelming, there remain so many ways trans people can fulfill their dreams of parenthood – and so many resources out there to help them.
“This is a landscape that is changing every minute, changing every hour, it seems,” Meg York, Director of LGBTQ+ Family Law and Policy and Senior Policy Counsel for Family Equality, told LGBTQ Nation. “And yet, at the same time… there are things that, at least today, remain constant. We need to be really grounded in what is accessible to us, to trans individuals, to LGBTQ+ individuals, and not engage in that anticipatory compliance of, ‘Oh no, they’re targeting the community so we won’t do things.’ What are my rights? How do I access them? What do I have access to? All of those are really important.”
Related
LGBTQ+ fertility coverage has made massive strides. Now fetal personhood threatens that progress.
Insurance companies have just begun to aknowledge the concept of “social infertility.” Despite the far-right crusade against IVF, activists have hope.
Family building for trans people will no doubt become more complicated as the GOP continues to attack trans rights. The current onslaught of anti-trans executive orders does not directly target those who are trying to have children, but it’s impossible to know what the future holds. Still, York cautions trans folks from letting hate intimidate them.
Never Miss a Beat
Subscribe to our newsletter to stay ahead of the latest LGBTQ+ political news and insights.
Subscribe to our Newsletter today
“The joy and belonging of family is so incredibly beautiful. I think it’s very important to not let fear shape your reality, but rather possibility. And there are so many possibilities that exist today.”
This guide explores several of those possibilities.
Sperm, eggs, & hormones
If would-be parents produce both sperm and eggs themselves, the key question is whether those gametes can create a viable pregnancy. While each person’s experience might vary, hormone replacement therapy is likely to at least somewhat reduce a trans person’s fertility. But that is very different from causing permanent infertility.
Sperm production
For those who have testes and are still producing sperm but have also been on estrogen and testosterone blockers, fertility will indeed have decreased, Kate Steinle, the Chief Clinical Officer from Folx Health told LGBTQ Nation. “Part of the side effect of [those medications] is that their sperm count decreases, their testicular size decreases, and therefore their fertility is decreased.”
But Steinle made clear that “if they were to go off of hormones… their fertility will start to increase over usually about a three-month period. That’s kind of the entire life cycle of a sperm.”
That being said, the fertility of someone producing sperm is not entirely elastic, and there are factors that can limit how much it bounces back. Steinle explains that two of the key factors here are age (which affects fertility in all people, whether they’re taking HRT or not) and how long someone has been taking estrogen.
A semen analysis can be done which not only informs a patient on their sperm count, but also on the health and motility of those sperm. That information can then help guide decisions around next steps and whether coming off hormones or trying another procedure makes sense.
Egg production
When it comes to people who have eggs, the matter of basic fertility is much simpler. Steinle notes that as long as someone who produces eggs hasn’t had operations to remove their ovaries, their fertility won’t be affected by gender-affirming care.
But creating a pregnancy through sex and/or using one’s own uterus still might not be the right choice for everyone with eggs.
The right uterus for you
While someone might be producing fertile eggs and be in a relationship with someone who produces fertile sperm, pregnancy itself might pose an issue. It is possible to become pregnant while taking testosterone, but medical providers warn against remaining on it (or restarting it after becoming pregnant) until the pregnancy has reached its conclusion.
Taking time off testosterone to become pregnant and carry a child might be viable for some, but it could also be extremely detrimental to the parent’s mental health.
When discussing the experience of coming off testosterone for pregnancy, one trans man told The Conversation, “My lows were miserable, depressed, to the point of suicidal.” Similarly, while two people might biologically be able to take part in reproductive sex, doing so might be too unappealing and dysphoric. In those cases, it might be time to look at storing eggs and finding a surrogate.
Preserving gametes
If it’s feasible, it is always advisable to store your sperm or eggs before starting gender-affirming hormones. Steinle highlights that even if you don’t plan to have children or don’t plan to have them until much later in life, it can ensure that the option is there and that you have a healthy supply if and when the time comes.
“It’s cheaper to store your sperm now before you start hormones, and your sperm count is going to be higher,” Steinle explains.
Sperm freezing is fairly straightforward, but the process for egg harvesting is more extensive. Most of the time, only a single egg is released during ovulation. Egg retrieval involves hyperstimulation of the ovaries so that multiple eggs are released, giving a higher chance of a successful embryo down the line. In the past, trans people had to come off testosterone for several months before egg retrieval was possible, but Steinle says that with the right patient and the right clinic, that’s no longer always the case.
“At this point, there’s a bunch of different programs out there that don’t actually require someone to come off of testosterone to be able to do the egg retrieval… it totally depends on their fertility testing and how things are going with their stimulation, but they sometimes can stay on a low level of testosterone, even during the IVF retrieval process.”
Preserving gametes isn’t always viable for would-be parents, though. The biggest impediment is often the cost. It’s expensive, and if you’re younger and planning for the future, you might not have that cash to spare. Insurance might be able to help, but that’s far from a certainty.
York discussed the importance of being able to offset the cost of these fertility preservation treatments: “At Family Equality, we’re working toward joining forces with a lot of fertility advocates to try to expand who can be covered by their insurance. Because we know that cost is a huge barrier for people accessing assisted reproduction, and when you’re trans, you have just another layer of hurdles to make sure that you can get the access to the care that you need.”
But those insurance coverage gains might not be as secure as we’d like. “Executive orders can’t override constitutional decisions [or] state law, and a lot of our access to family building and family protections is born of state law. [But] the federal government is involved in some funding of health insurance, and that is leaving us a bit unsure about what’s going to happen down the line.”
Steinle pointed to the issues that arise even when insurance does cover fertility preservation options. For trans couples there can still be roadblocks to receiving that coverage.
“Some insurances require you to [meet] a standard that is meant for cis heterosexual couples that are having sex that can create a pregnancy over a certain course of months and based on somebody’s age before covering treatment… When we think about people who, the sex that they’re having with their partners is not going to create a pregnancy… they have to go through out-of-pocket expenses for many, many months.”
IVF and surrogacy
If family-building is going to involve retrieved eggs, whether with a surrogate or a parent using their own stored eggs, that plan will require IVF. In IVF, the sperm and the egg are collected, combined to form an embryo, and then implanted into a uterus.
This means taking family-building out of the home and into a clinic. With a clinic, third-party donors, or a surrogate involved, there are additional concerns and hurdles to be aware of. Because you are dealing with more official bodies, there is a greater risk of government limitations on what can be done. Thus, it is important to understand and secure parentage rights.
IVF
Outside of the high cost, IVF can seem like the perfect solution for trans people looking to start a family. However, through 2024 we saw a skirmish around IVF’s legality as Alabama introduced an anti-abortion law that banned IVF, Republicans blocked a Democrat-led attempt to protect access to IVF, and then Trump spoke in favor of it, bizarrely declaring himself the “father of IVF.”
York discussed the complexities of understanding the attacks against IVF and the motivation behind them: “People who believe that abortion should be illegal in all circumstances are also often supportive of IVF… What we have to be very cautious of are these sneaky threats and these tactics that can chip away at our ability to actually access IVF…The people who are trying to attach personhood at conception, or prior to birth… the largest risks to IVF are some of the collateral damage from other attacks on reproductive autonomy.”
That risk of trying to attribute personhood to embryos is greater after one of Trump’s executive orders. While declaring there are only “two sexes,” the executive order also claimed that gender was based on conception. That’s a major red flag for where Trump, or at least the people who are writing his orders, want to take the country.
For now, IVF probably isn’t under huge threat, especially because Trump would have to contend with his past comments.
Surrogacy
Surrogacy largely relies on IVF remaining accessible but otherwise has limited threats. While it is illegal or lacking proper legal protections in some states, it is legal in most of the United States. Steinle is sure that it isn’t going anywhere because it typically is not covered by insurance: “All these things that the federal government can [do to] minimize or exclude coverage for certain things, like fertility treatments, they’re not going to really touch surrogacy because surrogacy isn’t even covered most of the time by commercial insurance, let alone federal insurance.”
While Steinle acknowledges that there is scope for issues like religious exceptions, for most agencies that handle surrogacies, that’s not going to happen. Surrogacy is more common in the LGBTQ+ community, so there are plenty of agencies that have been built around the community. Short of an unlikely legal restriction, those agencies aren’t going to change their practices.
Subscribe to the LGBTQ Nation newsletter and be the first to know about the latest headlines shaping LGBTQ+ communities worldwide.