Curr Obstet Gynecol Rep (2017) 6:149–155
DOI 10.1007/s13669-017-0212-4
CARE FOR THE TRANSGENDER PATIENT (C UNGER, SECTION EDITOR)
Reproductive and Obstetrical Care for Transgender Patients
Alexis D Light 1 & Shawn E Zimbrunes 1 & Veronica Gomez-Lobo 1,2
Published online: 9 May 2017
# Springer Science+Business Media New York 2017
Abstract
Purpose of Review The purpose of this article is to briefly
summarize some of the available reports regarding
fertility, reproduction, and obstetrical care for transgender
patients, as well as address some of the ethical and legal
considerations.
Recent Findings Transgender individuals desire reproductive
options but reproductive desires among individuals vary
significantly. Some options for cross-gender hormones can
permanently affect one’s ability to biologically reproduce.
Current standard of care is to offer fertility preservation prior
to transitioning, but emerging research suggests that there may
not be a high uptake in these options. Transgender men seek
out culturally competent obstetrical care.
Summary Reproductive care for the transgender population
involves issues such as the effects of cross-sex hormones
on fertility, fertility preservation, reproductive options,
pregnancy outcomes as well as psychosocial, ethical, and
legal considerations. Many of these areas are understudied,
leaving exciting opportunities for future research on how to
best care for this patient population.
This article is part of the Topical Collection on Care for the Transgender
Patient
* Alexis D Light
Alexis.D.Light@gunet.georgetown.edu
1
Washington Hospital Center Department of Obstetrics and
Gynecology, Washington, DC, USA
2
Director of Pediatric and Adolescent Gynecology, Children’s
National Health Systems/MedStar Washington Hospital Center,
Washington, DC, USA
Keywords Transgender . Reproduction . Fertility .
Obstetrics . Female-to-male . Male-to-female
Introduction
The World Professional Organization of Transgender Health
(WPATH) first charged healthcare providers to consider the
reproductive goals of their transgender patients in their 2001
Standards of Care [1]. Over the last decade and a half, there
has been increasing research published about the reproductive
wishes for transgender individuals as well as the way
healthcare providers can best support these wishes [2••]. In
2011, The American College of Obstetricians and
Gynecologists (ACOG) charged obstetricians and gynecolo-
gists (OBGYNs) to eliminate barriers to the care of transgen-
der patients, including assisting in the reproductive and ob-
stetrical needs of this population [3]. The current standard of
care set by both WPATH and the Endocrine Society is for all
transgender individuals to receive comprehensive counseling
on all fertility options prior to initiation of hormone blockers
and/or cross sex hormones [4, 5]. In the following article, we
will briefly summarize the current understanding regarding
fertility, reproduction, and obstetrical care for transgender pa-
tients, as well as address some of the ethical and legal consid-
erations. There is still a significant paucity of research on these
topics and much of what is currently being practiced is extrap-
olated from other fields such as oncofertility.
There are many terms used to describe transgender individ-
uals, with cultural preference for certain terms determined by
individual communities. In this chapter, we will use
“transmen” and “transgender men” to describe female-to-
male transgender individuals, and use the terms
“transwoman” and “transgender woman” to describe male-
to-female transgender individuals.
150
Reproductive Desires Among Transgender Patients
It was once assumed that transitioning one’s gender meant
sacrificing future reproductive wishes. New reports are pro-
viding evidence that transgender individuals desire to become
parents, being transgender does not preclude one’s ability to
be a good parent, and that healthcare providers can help assist
with reproductive options [6]. While some question the ethics
of transgender individuals having and raising children [7], the
American Academy of Child & Adolescent Psychiatry asserts
that there is no evidence that children are negatively impacted
by their parents’ sexual orientation or gender identity [8].
Transgender individuals have a vast array of reproductive
desires. One study found that 77% of 120 transwomen sur-
veyed agreed that cryopreservation of sperm prior to
transitioning should be offered [9]. Half of those asked would
seriously consider preserving their sperm if the option had
been offered. For transgender women who were counseled
but opted to not undergo cryopreservation, the option was felt
to be limited by time and finances [10]. As for transgender
men, the majority desire to be parents, with some desiring to
use their own oocytes or even carry a pregnancy themselves
[11]. Individuals who do choose to undergo fertility preserva-
tion have a wide range of thoughts on why to undergo the
procedures and how to cope throughout the process [12•].
There is insufficient evidence currently regarding transgender
youth and their desires for future fertility.
Effect of Cross-Sex Hormones and Gender
Affirming Procedures on Fertility
The effects of cross-sex hormones and gender affirming pro-
cedures on fertility are not fully known. Stages of medical and
surgical transitioning are often spread across a spectrum rang-
ing from reversible to irreversible treatment. Current evidence
supports beginning reversible hormone blocking on transgen-
der adolescents at Tanner stage 2 and initiation of cross-sex
hormones around the age of 16 for optimization of physical
and emotional health [4, 13].
There is significant debate, and little research, on the effects
of exogenous hormones on future fertility. Hormone blockers
used in peri-pubertal children are thought to be reversible as
they can be stopped, and if cross-sex hormones are not admin-
istered, the adolescent will then continue on with their natal
puberty. Cross-sex hormone administration is seen as partially
reversible but the full effects of cross-sex hormones on fertility
are not fully understood. Furthermore, the fate of gamete cells
exposed to cross-sex hormones prior to natal hormones are
also not known. Sterilization surgeries (hysterectomy with
oophorectomy or orchiectomy) are irreversible and thus these
surgeries are not usually performed on minors [13].
Curr Obstet Gynecol Rep (2017) 6:149–155
Puberty Blockers in Adolescents
Although puberty blockers are reversible, the adolescent
would need to proceed with natal puberty in order to mature
gametes. This presents a quandary for adolescents who desire
fertility but would experience distress if natal puberty were to
place. Furthermore, questions remain regarding the ability to
retrieve gametes in adolescents who have undergone puberty
suppression and have not yet experienced puberty. In addition,
the effects of cross-gender hormones prior to exposure to natal
hormones are to date unknown [14, 15].
Estrogen Treatment for Transwomen
Low levels of estrogen are necessary for male fertility.
However, both animal and human data suggest that higher
levels of exogenous estrogen may have a negative impact.
Rodent studies suggest that increasing the dose of estrogen
can alter sperm counts and the sperm’s ability to function
[16]. These effects may be reversible [17]. Obese men have
a higher risk for infertility compared to their normal weight
peers, thought to be from higher rates of circulating estrogen
created by peripheral adipose conversion [18]. The direct ef-
fects of exogenous estrogen on fertility, and reversibility, need
to be better demonstrated in human populations.
Testosterone Treatment for Transmen
Low levels of testosterone are needed for female fertility. Higher
levels of testosterone have been noted to be detrimental to ovar-
ian tissue causing follicular atresia in animal studies [19, 20]. In
women with polycystic ovarian syndrome (PCOS) which is char-
acterized in part by elevated androgens, and sertoli-leydig cell
tumors (testostosterone producing tumors), impaired
folliculogenesis and anovulation are common findings [21, 22].
However, fertility can be restored with correction of the under-
lying disorder. This raises questions, regarding the reversibility of
exogenous testosterone administration in transmen.
Reproductive Options for Transgender Individuals
Fertility preservation options for transgender individuals are
no different than the methods offered to cisgender individuals
[2••]. Information on trans reproduction and fertility preserva-
tion is currently being extrapolated from the oncofertility lit-
erature [23•, 24••].
Fertility Preservation
Fertility preservation options include sperm, ova, and embryo
as well as ovarian and testicular tissue cryopreservation. These
options allow for the possibility of a future child who is
Curr Obstet Gynecol Rep (2017) 6:149–155
biologically related to their parent, but may be invasive and
cost-prohibitive [25, 26]. Retrieval of sperm and ova for pres-
ervation are very different processes, with significant differ-
ences in invasiveness, cost, and outcomes.
The simplest and most effective method for sperm preser-
vation is through masturbation and collection of semen which
is then processed in an andrology lab and stored. There are
other theoretical methods such as testicular aspiration or ex-
traction from a postmasturbation urine sample [27]. Attitudes
of affirmed females towards these methods for sperm retrieval
have not been documented but some trans adolescents in the
author’s practice have opted for traditional sperm banking.
Oocyte preservation involves a process of hormonally stimu-
lating the ovaries to produce multiple mature follicles, closely
monitoring the development of these oocytes with sonograms
and change in hormone levels over a 2 to 3-week period, and
then retrieval of the oocytes through needle aspiration (often
intravaginally) [28–30]. Though researched since the 1980s,
and having undergone many improvements along the way, oo-
cyte preservation was still considered experimental until 2013
[31, 32]. While no longer experimental, it has a lower live birth
rate compared to the use of fresh oocytes or persevered embryos
[33, 34]. Again, attitudes of transmen towards this procedure
have not been documented but cases have been reported [23].
From our clinical experience, and findings at other institu-
tions, it seems that both oocyte and sperm cryopreservation
appear to have low uptake in the adolescent trans populations
in spite of consistent counseling [35•]. More research needs to
be done to assess why this might be the case, what the long-
term implications are, and to determine how to best counsel
patients on fertility preservation prior to transitioning.
Embryo preservation (most commonly known as in vitro
fertilization (IVF)) is the process of retrieving mature oocytes
from an ovary (done as outlined in the above section) that are
then fertilized with sperm from a known or anonymous donor
and then cryopreserved to be stored for later use [36, 37].
While oocyte and embryo cryopreservation are the more
straightforward and successful options, they may not appeal
to transgender men as they require hormonal maturation and
transvaginal harvesting of ova [38]. Additionally, transgender
men who have undergone hysterectomy or who do not desire
to carry a pregnancy, would need to rely on a gestational
surrogate (a partner or another woman) [39••].
Gonadal tissue cryopreservation is a potential option for fer-
tility preservation when there are barriers to gamete preservation,
such as limited time for oocyte maturation or a prepubertal pa-
tient. To date, over 60 pregnancies have been reported with re-
implantation of ovarian tissue; however, it is still considered
experimental. Additionally, individuals who have undergone pu-
berty suppression present unique challenges. These patients are
thought to be too young when initiating cross-sex hormones to
undergo permanent surgical elective gonadectomy, but extracting
their gametes for cryopreservation may not always be feasible. It
151
is accepted that the ability to extract sperm requires pubertal
development to Tanner 3 but it is unknown if ovarian stimulation
and egg retrieval can be accomplished in individuals who have
not reached this stage in development [40, 41].
Reproduction
There are a multitude of ways that transgender patients may
choose to reproduce including adoption and surrogacy.
Options an individual or couple choose to pursue reproduction
heavily depends on the availability of gametes and a uterus as
well as personal preference. Media attention has been given to
transgender men who choose to carry a pregnancy and this
may not be a rare phenomenon as noted by a case series of 41
transmen who became pregnant after transition [42, 43••].
There is a growing list of case reports [44, 45] and resources
available for transgender men interested in pregnancy [46].
Little is known at this time about the reproductive wishes
and all the complex factors that influence a transgender indi-
vidual’s decisions on reproduction [47].
A future possible option for transwomen has been
highlighted by the report of successful live births after uterus
transplant in cisgender women; however, to date, the research
protocols and specific ethical guidelines have excluded trans-
gender individuals [48].
Fertility and Mental Health in the Transgender
Patient
Transgender individuals have a higher rate of depression and
suicidal ideation compared to their cisgender peers for multi-
ple reasons, including higher rates of discrimination, assault,
and rejection from family and community [49]. It is therefore
not surprising that the literature has shown that transgender
men who undergo pregnancy experience a high rate of lone-
liness in the process of becoming biological parents [50].
Transmen are also at a high risk for experiencing increased
gender dysphoria in pregnancy and for postpartum depression
[43••, 51]. It is crucial that healthcare providers screen their
patients for mental health concerns during the reproduction
process and provide necessary support.
Obstetrical Care for Transgender Patients
Public media has shown that transgender men are choosing to
reproduce, and therefore need access to quality obstetrical care
[52]. When questioned about their pregnancy, transgender
men drew attention to situations that may heighten gender
dysphoria during the pregnancy—pointing out that some ob-
stetric provider’s offices lack male bathrooms, hospital and
clinic staff members are often not culturally competent, and
152
sitting in shared waiting rooms may be awkward for pregnant
patients who physically appear male [43••]. This highlights
the need for healthcare settings that are able to support trans-
gender male patients during preconception counseling, preg-
nancy, birth, and the postpartum period.
Preconception Counseling
Healthcare providers should be prepared to provide appropri-
ate preconception counseling to all their patients, including
trans individuals. According to the American Academy of
Pediatrics and the American College of Obstetricians and
Gynecologists, the basic tenants of preconception counseling
include an assessment of overall health and wellness, a dis-
cussion of basic nutrition and vitamin supplementation, and a
review of current medications. Additionally, a genetic screen-
ing is appropriate for certain high risk populations or individ-
uals with a family history of certain inheritable disorders [53].
Health assessments should include a review of chronic
medical history issues that have known adverse effects during
pregnancy such as hypertension, diabetes, and a history of any
seizure disorder. Identification of risk factor such as substance
abuse, environmental exposure, history of domestic abuse and
overall safety should also occur. A plan to address and/or
modify these risk factors should follow. Any nutrition
counseling should include a discussion of prenatal vitamins,
and specifically mention the Center for Disease Control rec-
ommendation of 0.4 mg of folic acid supplementation initiated
at least 1 month prior to conception in order to decrease the
risk of neonatal spine and brain defects [54]. The current rec-
ommendations are that testosterone therapy should not be
continued during pregnancy but there is not data regarding
the timing of testosterone cessation [55].
As mentioned previously, gender dysphoria and feelings of
loneliness are more pronounced in pregnancy and in the post-
partum period [43••]. Given that pregnancy for a transgender
patient can pose the unique challenge of loss of one’s gender
identity, it could be beneficial to openly discuss plans for
coping strategies [50] and help establish care with a mental
health professional prior to pregnancy if desired.
Pregnancy
Clinical management of transgender men during pregnancy
should follow guidelines for routine obstetric care [51]. A
questionnaire study of 41 transgender men who had under-
gone pregnancy and childbirth brings to light to some unique
issues [43••]. Findings included a short interval to pregnancy
after stopping testosterone (usually less than 6 months) and
even some unplanned pregnancies while on testosterone. This
is concerning as exposure to exogenous testosterone during
embryogenesis may lead to virilization, metabolic dysfunc-
tion, and future reproductive issues in the offspring [55].
Curr Obstet Gynecol Rep (2017) 6:149–155
This series also revealed significant self-reported rates of hy-
pertension (12%), preterm labor (10%), and placenta abrup-
tion (10%) but these data are limited by the methodology [56].
Furthermore, there is evidence that elevated endogenous ma-
ternal testosterone levels during pregnancy may be associated
with low birth weight [57, 58•].
Birth
A typical labor process for a vaginal delivery can involve
multiple digital vaginal examinations by a provider, an expec-
tation that should be addressed prenatally. In the previously
mentioned series 71% of patients had a vaginal delivery, while
30% had a cesarean section (with 25% undergoing elective
cesarean section). A significant percentage of these study par-
ticipants chose to deliver at home or in an independent
birthing center [43••]. It is thus important that the provider
inquire about each patient’s preferences, and assist in devel-
oping a safe and appropriate birth plan along with the patient.
Postpartum
As previously mentioned, transgender male patients who un-
dergo pregnancy are at increased risk of postpartum depres-
sion [51]. It would therefore be prudent to consider the addi-
tional support of a mental health provider in the postpartum
period if one has not already been a part of prenatal care.
Lactation is an important topic to consider when caring for
these individuals. In the previously cited series, 51% of trans-
gender men chestfed (term used in the transgender community
for “breastfed”) after delivery [43••]. This can be accom-
plished before or after breast gender affirming surgery (“top
surgery”) as some men have been found to lactate following
chest reconstructive surgeries [59]. Optimal counseling and
education is key for success [60]. Currently, the recommenda-
tion is to avoid chestfeeding while on testosterone [61]. It is
important to note, however, that current toxicology data states
that testosterone has low oral bioavailability, and therefore it is
unlikely to affect a nursing infant [62].
There is debate regarding the ideal timing for restarting
testosterone therapy [63]. Unfortunately, outside of the recom-
mendation for transgender men not to restart testosterone ther-
apy if they are chestfeeding [54], there is a paucity of data to
guide counseling on the matter.
Ethical and Legal Considerations
Ethics
There are multiple ethical principles to address when
discussing transgender reproductive and obstetrical care.
Autonomy is the most straightforward ethical issue as it has
Curr Obstet Gynecol Rep (2017) 6:149–155
long been the principle supporting the reproductive justice
movement [63]. Being transgender does not negate a person’s
personal decision to reproduce. The principle of justice sup-
ports a transgender individual’s autonomous right to repro-
duce, use advanced reproductive technologies, or fertility
preservation services [64–66]. The principle of justice would
support that it is only permissible to deny services to similar
groups (cisgender and transgender individuals) if there is ev-
idence of serious harm to one of the groups and at this time,
there is no evidence of harm from transgender reproduction
[64]. With regard to beneficence and nonmaleficence, repro-
ducing may be advantageous to certain individuals, and while
a concern of some, there is a growing body of evidence to
support that having transgender parents does not cause nega-
tive outcomes in children [64].
Legal
The legal discussion is highly dependent on the local
governing laws for the individuals involved [67]. There are
many countries and areas of the USA that require sterilization
or other surgery affirming procedures in order for the individ-
ual to legally transition genders [65, 66]. Additionally, country
specific laws determine who can be identified on a birth cer-
tificate and assign the rights to parenthood [68]. Recently
there has been an ongoing dialogue regarding the legal rights
of transgender individuals, including their right to fertility and
to parenthood [68]. This is a discussion that is beyond the
scope of this review.
Conclusion
Healthcare providers should offer comprehensive, culturally
sensitive, and personally directed care to their transgender
patients just as they should for their cisgender patients.
Reproductive care for the transgender population involves is-
sues such as the effects of cross-sex hormones on fertility,
fertility preservation, reproductive options, pregnancy out-
comes as well as psychosocial, ethical and legal consider-
ations. Many of these areas are understudied, leaving exciting
opportunities for future research on how to best care for this
patient population.
Compliance with Ethical Standards
Conflict of Interest Alexis Light, Shawn Zimbrunes, and Veronica
Gomez-Lobo declare that they have no conflicts of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
153
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