Fertility and transgender people

The possibility of having children is a concrete concern for many transgender people. The fear of losing this option forever is one of the factors that most influences decisions about the gender-affirming pathway. A survey conducted in Belgium found that over 54% of trans men wished to have children even after completing their transition [4]. The reality is that there are several paths to parenthood, and science now offers options worth knowing about before making any decision.

This article examines the effects of hormone therapy on fertility, the preservation options available, the legal situation in Italy, and the psychological aspects related to these choices.

Effects of hormone therapy on fertility

Gender-affirming hormone therapy (GAHT) has a significant impact on reproductive capacity. However, this impact is not always total nor always permanent [10]. The effects vary based on the type of hormones taken, the duration of treatment, and individual characteristics.

Estrogens and anti-androgens (trans women)

In trans women, therapy with estrogens and anti-androgens suppresses the hypothalamic-pituitary-gonadal axis, drastically reducing testosterone levels and inhibiting spermatogenesis. In most cases, azoospermia (absence of sperm in the seminal fluid) is observed within 3-6 months of starting therapy [7].

A histological study conducted on testicular tissue obtained during orchiectomy found that spermatogenesis was present in only 28.2% of the samples examined, with active spermatogenesis in just 8.2% of cases [7]. These data confirm a significant impact, but also show that some residual activity can persist in some individuals.

The good news is that recent research suggests a possibility of recovery. A study published in 2023 in Cell Reports Medicine documented the restoration of spermatogenesis in nine trans women who had discontinued hormone therapy for reproductive reasons. Viable sperm were identified as early as 3 months after discontinuation, and four of the participants conceived naturally with their partners [3]. This study, while having a small sample, indicates that GAHT-induced suppression of spermatogenesis may be transient in some cases.

However, recovery is not guaranteed. The duration of therapy appears to be a determining factor: discontinuation within the first 6 months of treatment tends to allow faster recovery, while treatments extending beyond 2-3 years can significantly reduce the chances of complete restoration [10].

Testosterone (trans men)

In trans men, exogenous testosterone interrupts ovulation and can cause endometrial atrophy. However, scientific evidence shows that the impact on ovarian reserve may be less drastic than previously thought [6].

A study presented in 2019 demonstrated that after one year of testosterone therapy, anti-Mullerian hormone (AMH) levels, an indicator of ovarian reserve, remained within normal values for fertility [6]. This suggests that ovarian function is preserved at a level that could still allow reproduction.

Research on animal models has confirmed that testosterone-induced cycle suppression is reversible after discontinuation, although reversibility depends on the duration of treatment [6]. Short periods of therapy show more complete recovery compared to prolonged treatments.

The Endocrine Society guidelines (2017) and the WPATH Standards of Care version 8 (2022) recommend clearly informing transgender individuals about the known and still poorly studied effects of hormone therapy on fertility, emphasizing that reversibility cannot be taken for granted [9][1].

Fertility preservation before hormone therapy

The ideal time to preserve fertility is before starting any hormone therapy or surgical intervention. International guidelines, including those of WPATH (2022), the Endocrine Society (2017), and ASRM (2021), unanimously recommend that fertility counseling be offered to every transgender person as an integral part of their care pathway [1][9][5].

Options for trans women

Semen cryopreservation is the most established and accessible technique [10]. The process involves collecting one or more sperm samples through masturbation, which are then frozen and stored in liquid nitrogen indefinitely.

Alternatively, when collection through masturbation is not possible or does not produce adequate samples, more invasive techniques can be used, such as testicular needle aspiration or surgical sperm extraction (TESE). Testicular tissue cryopreservation is also available, a technique still considered experimental but promising for younger individuals who have not yet reached puberty [10].

Options for trans men

Oocyte cryopreservation requires an ovarian stimulation cycle lasting approximately 10-14 days, with daily gonadotropin injections and ultrasound monitoring, followed by oocyte retrieval under sedation. Mature oocytes are then cryopreserved using the vitrification technique [10].

Embryo cryopreservation follows the same process but involves fertilizing the oocytes before freezing. This option requires the availability of sperm (from a partner or donor) and offers slightly higher thaw survival rates.

Ovarian tissue cryopreservation is a technique that consists of harvesting and freezing fragments of ovarian cortex. It is considered an important option especially for prepubertal adolescents [5]. The ASRM removed the experimental label from ovarian tissue cryopreservation in 2019.

Fertility preservation during or after hormone therapy

Not everyone decides to preserve fertility before starting hormone therapy. Some do not receive adequate information in time, others do not feel ready to make this decision, still others change their mind over time. Even in these cases, there are possibilities.

Discontinuation of hormone therapy

Temporary discontinuation of GAHT is the most studied option. As previously described, spermatogenesis can resume in trans women after discontinuing estrogens [3], and ovulation can return in trans men after discontinuing testosterone [6]. The time needed for recovery varies from person to person: from a few months to over a year.

This option requires careful evaluation with one’s endocrinologist, because discontinuing hormone therapy can have significant consequences on psychological and physical well-being. Not everyone is willing to face this step, and the decision must be respected.

Gamete retrieval during therapy

A study demonstrated that it is possible to obtain mature oocytes from trans men even during testosterone therapy, without the need for prior discontinuation. The quality of oocytes in terms of fertilization rates and preimplantation embryo development proved comparable to that of cisgender women [10]. However, this remains an area of active research, and current standard practice still calls for discontinuing testosterone before ovarian stimulation [9].

Trans men and pregnancy

Pregnancy in trans men is a topic receiving increasing attention in the scientific literature. The pioneering study by Light et al. (2014) documented the experiences of 41 trans men who had carried a pregnancy after beginning their transition pathway [2].

What the research revealed

Among the study participants, 61% (25 people) had used testosterone before pregnancy. The average age at conception was 28 years. 88% conceived with their own oocytes. 44% gave birth with the assistance of midwives, and 78% gave birth in hospitals [2].

These data demonstrate that pregnancy is possible even after a period of testosterone therapy, provided that the uterus and ovaries are still present and that testosterone is discontinued during gestation. Testosterone is teratogenic and must be stopped before conception [9].

Practical and medical aspects

Pregnancy in a trans man requires attentive and competent medical care. Unfortunately, the Light et al. study revealed low levels of knowledge and awareness among healthcare providers regarding the specific needs of pregnant trans men [2].

Discontinuing testosterone can cause the return of menstruation, changes in fat distribution, and other effects that can be a source of significant distress. Adequate psychological support throughout the journey is essential.

An evolving topic

In recent years, the visibility of trans male pregnancy has increased in the medical community and in society. Various healthcare facilities are developing specific protocols to follow trans men and non-binary people during pregnancy, although the journey often remains complicated by the lack of specific training among medical personnel [1].

The legal situation in Italy

The Italian regulatory framework presents significant challenges for transgender people who wish to have children, whether through medically assisted reproduction or through adoption.

Medically Assisted Reproduction (MAR)

Law 40/2004 regulates MAR in Italy and allows access exclusively to opposite-sex couples, married or cohabiting. This means that single individuals and same-sex couples are excluded, regardless of their transgender status.

A trans person who has completed their legal gender recognition and who is in an opposite-sex couple (for example, a trans man with a cisgender male partner, both with rectified documents so as to appear as a heterosexual couple) can formally access MAR. In practice, however, access remains complicated by restrictive interpretations and the lack of specific protocols.

Constitutional Court ruling 155/2025

An important legal development is represented by ruling no. 155/2025 of the Constitutional Court [12]. The case concerned a person who in 2014 had begun the gender rectification process from male to female and who in 2018 had had a daughter through MAR using their own male gametes, cryopreserved before transition.

The Court clarified that Law 40/2004 does not prevent recognition of biological parenthood for a person who provided male genetic material for MAR and who subsequently became a woman [12]. The subsequent gender change does not affect the biological bond between parent and child. This is a relevant ruling because it implicitly recognizes the value of fertility preservation in the gender-affirming pathway.

Adoption

Adoption in Italy is regulated by Law 184/1983, which provides for full adoption only for married couples. A trans person who has completed legal gender recognition and who is in a heterosexual marriage can theoretically access adoption. In practice, the pathway is often hindered by cultural prejudices and the discretion of juvenile courts in assessing parental fitness.

So-called adoption in special cases (Article 44 of Law 184/1983) represents a more accessible possibility but offers more limited legal protections compared to full adoption. Access to adoption for transgender people remains a topic largely absent from Italian political debate.

Costs and accessibility in Italy

The costs of fertility preservation in Italy vary considerably based on the technique used and the facility chosen.

Semen cryopreservation

The initial cost is approximately 300 to 800 euros, plus an annual maintenance fee ranging from 100 to 300 euros. This is the most economical and least invasive procedure among all available options.

Oocyte cryopreservation

The complete pathway, which includes ovarian stimulation, ultrasound monitoring, oocyte retrieval under sedation, and cryopreservation, costs approximately 1,500 to 7,000 euros, depending on the center. An annual maintenance cost is also added.

2025 update: the LEA

A significant change is the inclusion of MAR in the Essential Levels of Care (LEA) in 2025. MAR-related services, including oocyte cryopreservation for fertility preservation purposes, can now be provided through the National Health Service, with a patient contribution in the form of a co-pay generally between 100 and 300 euros. However, not all public centers have yet activated these services, and coverage varies from region to region.

Tax deductibility

Since 2024, expenses for oocyte cryopreservation are 19% tax-deductible in the tax return (730 form), an additional benefit that makes fertility preservation more economically accessible.

Barriers to access

Despite regulatory improvements, barriers remain significant. The Infotrans.it portal, an institutional resource of the Italian National Institute of Health, notes that not all MAR centers have experience working with transgender people, and the lack of specific protocols can make the pathway more complicated and stressful than it should be [11]. Wait times in the public system can also be long, which is a problem when the person wishes to start hormone therapy as soon as possible.

Psychological aspects

Decisions about fertility are deeply intertwined with the identity, psychological well-being, and life plans of trans people. Several studies have explored the emotional complexity of these choices.

The conflict between urgency and planning

Many trans people experience a conflict between the urgency of starting hormone therapy to alleviate gender dysphoria and the need to take time to preserve fertility. The study by Chen et al. (2019) on transgender adolescents and young adults identified gender dysphoria as one of the main barriers to fertility preservation: the necessary procedures, such as ovarian stimulation for trans men or semen collection for trans women, can amplify body-related distress [8].

The financial burden

The same study identified costs as another determining factor [8]. When fertility preservation represents a significant expense, in a context where many other medical expenses already burden the person, the decision becomes even more complex.

The role of family

Family values regarding biological parenthood significantly influence decisions about fertility preservation [8]. Some families pressure the person to preserve their gametes, others do not understand the importance of this option. An open and non-judgmental dialogue within the family unit can help, but is not always possible.

The importance of adequate support

Psychological support during the decision-making process is essential. Mental health professionals working with trans people should be prepared to address these topics with competence and sensitivity, helping each person explore their desires without pressure in any direction [1].

Not wanting children is an equally valid choice. Not all people, transgender or cisgender, wish to become parents, and no one should feel obligated to preserve their fertility.

Practical steps

If you are starting or considering a gender-affirming pathway and parenthood is an important topic for you, here are some concrete steps.

Talk to your endocrinologist or primary care provider as soon as possible, ideally before starting hormone therapy. Ask for specific information about the preservation options available in your area [9].

Consult a fertility center to get a clear picture of costs, timelines, and procedures. Some centers have specific experience with transgender patients.

Learn about your rights. The Infotrans.it portal of the Italian National Institute of Health offers updated information on fertility preservation in the gender-affirming pathway [11].

Do not feel obligated to decide immediately. If you need time to reflect, talk to your doctor to understand whether it is possible to start hormone therapy and preserve fertility at a later time, while knowing that the ideal timing is before starting treatment.

Seek psychological support if the decision causes you anxiety or conflict. An experienced professional can help you explore your desires and fears without judgment.

In summary

Transgender people can have children. Options include fertility preservation before hormone therapy, temporary therapy discontinuation to recover reproductive capacity, direct pregnancy (for trans men who retain their uterus and ovaries), adoption, and assisted reproduction. The Italian legal framework still presents significant obstacles, but science and case law are moving toward greater recognition of the reproductive rights of transgender people.

The most important thing is to receive complete and timely information, ideally before starting any therapy, to be able to make conscious choices that respect one’s own life desires.