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Hormone therapy is an exciting step for anyone as one of the many tools of embodiment and gender empowerment. For those who take estrogen gender-affirming hormone replacement therapy (GAHT), there is a wide range of changes in physical effects from breast growth to skin softening and more.
Estrogen may impact fertility. We want you to know that taking GAHT doesn’t automatically make someone infertile. For context, we at FOLX use anatomical language to introduce the topic of fertility for clarity and shared understanding. However, we encourage you to use whatever language feels best for you, especially when speaking to your clinician or healthcare provider.
Estrogen can decrease your fertility by impacting the production and release of sperm. Estrogen affects the parts of the assigned male reproductive system known as the testes. The testes are the part of the body that produces sperm. Studies on the effects of long-term estrogen use are mixed. Long-term estrogen usage may result in results in lower testosterone levels, and lower testosterone levels in some people lead to testicular atrophy no longer producing sperm, and in other people, no changes to sperm production or the testes architecture occur. Sperm maturation and motility can be impacted by E, as well as the ability to get an erection. Maintaining an erection and ejaculation are also affected by taking estrogen, as the high levels of estradiol stop the brain from signally the testes to make testosterone. With that said, your ability to ejaculate and also sperm count required to create a pregnancy may decrease on estrogen GAHT.
Estrogen and testosterone blockers don’t prevent pregnancy.
It’s important to know that pregnancy is still a possibility for those who are having penetrative sex that involves the sperm from one person entering the vagina/front hole of an egg-producing partner. Just because someone is on estrogen HRT doesn’t mean they aren’t producing any sperm.
Likewise, if someone with ovaries is on testosterone, it doesn’t mean they aren’t ovulating! Under these conditions, it’s possible to get someone pregnant if neither party is using birth control methods.
Estrogen GAHT doesn’t act as birth control.
If someone wants to continue having the type of sex that could result in pregnancy without the risk of impregnating someone, they should employ birth control options for themselves and/or their partner(s). If you’re intentionally trying to create a pregnancy while on estrogen and/or T blockers with a consenting partner, understand that this can come with limitations. This can be more difficult given the decrease in fertility that comes alongside taking estrogen HRT.
Don’t worry: you still have fertility options. You can start your journey by conducting a semen analysis (also known as a sperm sample) to assess current fertility levels on hormones.
“Sometimes just starting with a semen analysis while you are on hormones is a great idea,” Kate Steinle, FOLX Chief Clinical Officer and nurse practitioner explains, “You can get a sense of your current fertility (measured through semen parameters of sperm count, motility, morphology, etc.) while you are still on hormones. Your fertility might be good! Or you might have sub-optimal fertility and have to take some steps to increase it.”
If your semen analysis concludes the effects of estradiol mean your sperm quality or quantity isn't suitable to create a pregnancy, you can choose to pause taking hormone medication. We understand this is not a desirable nor even possible option for many people. However, if you’re open to going through with this option, this may be one of the most cost-efficient options for you. Be sure to prepare emotionally for the amount of time it can take and practice patience.
“Most of the time, in order to get a semen sample that is of high enough fertility to freeze/store, someone will have to go off their hormones for a certain amount of time—often about six months,” adds Steinle. “However, this is very dependent on the individual. Some people will regain fertility faster, and some people may never regain fertility high enough to produce a good semen sample to freeze.”
Sperm freezing can happen before or after estrogen GAHT.
While we recognize that sperm storage is not financially feasible for many transgender people, some people choose to store their sperm for a future pregnancy before beginning estrogen both because of the impact of E on fertility, as well as the reality that younger age is connected to how fertile someone is.
It’s ideal to store sperm early on and before starting hormone treatment if possible.
“The best time to store sperm is before you start hormones—one, because you are the youngest you will ever be (and older age leads to decrease in fertility), and your sperm production has not been limited by taking estrogen,” says Steinle. “However, we know that some people are not ready or not able to do that. Even though it is usually more ideal to freeze sperm before starting hormones, you can definitely store sperm after you have started hormones.”
Local fertility clinics or sperm banks are credible fertility preservation options for storage. Other people choose to use at-home storage kits. Prior to storing sperm, it's a good idea to get a semen sample analysis for sperm count (how many), motility (how many can move), and morphology (how many are a normal shape) to ensure sperm is fertile enough to store. If someone has trouble with ejaculation, there are also surgical options for sperm extraction.
Depending on how long you’ve been on hormones, as well as other factors that affect individual fertility (age, health conditions, etc), your sperm may not be fertile enough to create a pregnancy while still taking estrogen. In that case, there is the option to go off of hormones for a period of time to see if sperm production can recover somewhat and reach a higher level of fertility.
Steinle notes that creating a more fulfilling lifestyle can also increase fertility, particularly through stress management, adequate sleep, exercising, balanced meals, acupuncture as well as Vitamin C and D supplements.
If you use your stored sperm in the future, one option is to use intracytoplasmic sperm injection (ICSI) to fertilize an egg before implanting the embryo in a uterus. Alternatively, there is the fertility treatment option to place the stored sperm directly into the uterus of someone carrying the pregnancy called intrauterine insemination.
There’s tremendous space for improvement in the sex education and family planning world for LGBTQ+ people. In the meantime, check out this article about fertility options for nonbinary and transgender people on GAHT. For existing FOLX members with further questions about estrogen and fertility options, consider scheduling an appointment with a provider. For anyone who isn't a FOLX member, contact us at email@example.com. We’re here to help!