Choosing gender-affirming care doesn’t have to mean giving up your dream of becoming a parent. While it’s true that hormone therapy, puberty blockers, and certain surgeries can affect fertility over time, you still have options. Many transgender and nonbinary patients choose to preserve their eggs or sperm before they start treatment. 

Even if treatment is underway, it’s rarely too late to explore the possibility of building a family. Below, we cover what the latest research says, along with a few key questions to ask your fertility specialist. 

How Gender-Affirming Hormone Therapy Affects Fertility  

Testosterone therapy suppresses ovulation and stops the ovaries from maturing eggs on a regular cycle. Over time, this changes the hormonal environment eggs develop in. Researchers are still studying exactly how much long-term testosterone use affects egg quality and quantity.  

For transgender women, estrogen and anti-androgen therapy work in a similar way by reducing sperm production and lowering sperm count and motility.  

Fertility changes depend on how long you’ve been on hormone therapy and the age you started. Individual biology also plays a role, which is why there’s no single timeline that fits everyone.  

Current research suggests that many individuals retain fertility well into their hormone therapy. A 2023 systematic review in Transgender Health looked at case reports and cohort studies on oocyte retrieval in transgender men on long-term testosterone and found that ovarian stimulation results in successful egg retrieval, even after prolonged testosterone exposure.  

The review also found no clear link between how long testosterone therapy was paused and how many oocytes were retrieved. This challenges the common assumption that a longer pause produces better outcomes.  

If you’d like to learn more about the science of egg freezing after testosterone therapy, we’ve covered that research in detail in a separate post: Egg Freezing for Transgender Men.  

Fertility Preservation and Puberty Blockers for Younger Patients  

Puberty blockers temporarily pause the body’s natural production of mature eggs or sperm. For adolescents and young adults, this shifts how we think about fertility preservation, as there are no mature cells available to freeze yet.  

To make freezing possible, some young people stop using puberty blockers briefly to allow puberty to progress enough to collect mature eggs or sperm, after which they can resume their original care plan. It’s a personal decision that families make with their care team, balancing medical timelines with the young person’s emotional readiness. 

Fertility Preservation for Transgender Men and Transmasculine Patients  

Choosing to freeze eggs before starting testosterone offers the clearest starting point for egg quality and quantity, simply because the retrieval happens before hormone therapy can affect eggs. But if you’ve already started testosterone, you haven’t missed your opportunity.  

A 2019 study published in Fertility and Sterility found that transgender men who paused testosterone to freeze their eggs retrieved them at rates comparable to cisgender patients, and the pregnancy outcomes from those eggs were just as successful.  

This option does require a temporary pause in testosterone to allow your menstrual cycle to return for the retrieval. For many, stepping back from hormone therapy can feel like a difficult emotional or physical trade-off. Your care team can help you plan the timing of that pause and manage symptoms as your cycle returns. 

Once your eggs or embryos are safely frozen, you have several paths to parenthood: you can choose to carry the pregnancy yourself, use a gestational carrier, or pursue reciprocal IVF with a partner who carries the pregnancy using your eggs.  

It takes two to three weeks from the start of ovarian stimulation for the ovaries to be ready for the egg retrieval procedure. You’ll use injectable medications to support egg development, and the care team will monitor your follicle growth with bloodwork and ultrasounds along the way.  

The retrieval itself takes about 20 minutes under sedation. Since frozen eggs or embryos can be stored for years, you have the freedom to resume testosterone and plan your family on your own timeline. 

Fertility Preservation for Transgender Women and Transfeminine Patients  

For transgender women and transfeminine patients, sperm freezing is the most common and effective way to preserve fertility before starting estrogen or anti-androgen therapy. The process is not invasive and can usually be completed in a single visit. It’s also one of the most accessible ways to preserve your fertility.  

As with any hormone therapy, time is a key factor. Sperm quality and production decrease the longer you’re on estrogen or anti-androgens. Freezing your sperm before starting treatment, or as early as possible, gives you the most viable samples to work with.  

What to Expect  

During a typical sperm freezing appointment, you’ll provide a semen sample in a private room at the clinic. The laboratory will immediately analyze, protect, and freeze the sample into multiple vials. If producing a sample through ejaculation isn’t possible or causes too much dysphoria, a brief testicular extraction procedure under light sedation offers another path to a viable sample.  

Once frozen, your samples can remain in storage for decades, so there’s no rush to use them.  

Already on Hormones?  

If you’ve been told that starting hormone therapy means permanent sterility, the science says otherwise. A promising 2023 study published in Cell Reports Medicine followed nine transgender women who paused their hormone therapy to retrieve sperm. All nine participants successfully recovered viable sperm.  

While this was a small study and we need more research to understand how consistently this happens for everyone, these findings are encouraging. They offer solid, scientific ground to explore your fertility options with a specialist, even if you’ve been on hormone therapy for years. 

Many people successfully pause their hormones to allow sperm production to recover. Even with a lower sperm count, modern family-building techniques like in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI), where a single sperm is paired with an egg, make pregnancy achievable.  

Nonbinary Patients: There’s No Single Path  

Being nonbinary is a personal experience, which means gender-affirming care is never one-size-fits-all. Some individuals choose hormone therapy, others pursue surgery, and some choose neither. No matter your decision, your fertility preservation planning should mirror your personal care goals and anatomy.  

For example, a nonbinary individual assigned female at birth who’s considering testosterone has the same egg-freezing choices as a transgender man. Someone assigned male at birth considering estrogen has the same sperm-freezing paths as a transgender woman.  

Those options overlap because they’re based on anatomy, not identity. Your care plan should reflect not only what your body can do, but also who you are. The biggest difference is the care and conversation behind it. An experienced provider will talk with you about your personal goals for your body and your future family. 

What Fertility Preservation Costs  

Egg freezing costs several thousand dollars per cycle. While many individuals retrieve a healthy number of eggs in a single cycle, some choose to undergo a second. Your age and ovarian reserve (the number of eggs remaining in your ovaries) are the most significant factors in deciding if a second round makes sense for you.  

Sperm freezing is often less expensive—a few hundred dollars per collection, plus an annual storage fee that applies to eggs and sperm as long as your samples remain frozen.  

Insurance coverage varies depending on your state and plan. Individuals in New York and New Jersey have certain state-mandated protections for IVF and medically necessary egg freezing. But because definitions of medical necessity vary, confirm with your insurer whether gender-affirming fertility preservation is covered under your plan.  

If you live outside of a state with these mandates, these services are usually paid out of pocket, though an increasing number of employers now offer inclusive fertility benefits. A financial counselor at the fertility clinic can walk through the exact costs and any financing or grant programs, including nonprofit grants you might qualify for.  

When to Talk to a Fertility Specialist  

The best time to speak with a fertility specialist is before you start hormone therapy. But if you’ve already started, a fertility specialist can help guide you through the next steps.  

Your first appointment typically starts with a routine blood test to check your hormone levels. From there:  

• If you have ovaries: Your team will perform a quick ultrasound to count your follicles (the tiny fluid-filled sacs that hold your eggs).  

• If you have testes: Your baseline test is a semen analysis.  

During this visit, your care team will review all of your current medications, including your hormone therapy, to make sure nothing interferes with your fertility plan. You’ll share your goals for your future family so your specialist can help you create a plan.  

Aligning fertility preservation with your broader care takes careful coordination, especially if you’re working with a surgeon on a timeline for other procedures. At Extend Fertility, we communicate with your other healthcare providers. This ensures that egg or sperm freezing happens when it’s the right time for you. 

Fertility decisions already come with a lot of uncertainty. Choosing a clinic experienced in working with transgender and nonbinary individuals can minimize frustration and give you the confidence that you’re getting the best possible care.  

Honoring Who You Are While Preserving Your Family-Building Options  

No matter where you are in your care, you can still take steps toward future parenthood.  

Whenever you’re ready, reach out to our fertility team. Our specialists can answer your questions and help you take control of your reproductive future while affirming who you are.