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Transgender Testosterone Hormone Replacement Therapy and Fertility 101

Written By

FOLX Health

Apr 12, 2022

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Are you looking for how estrogen impacts fertility? Click here to read our Estrogen HRT and Fertility article!

Although healthcare conversations around fertility often revolve around cisgender women, we’re here to remind you that fertility can be just as important for transgender men, non-binary people, and other gender-expansive people. Contrary to popular belief, there are several family planning options for those on all routes of hormone replacement therapy (HRT). Fertility treatment, also known as assisted reproductive technology by the American Society for Reproductive Medicine, is not reliant on any one particular gender identity.

Whether you’ve been on testosterone gender-affirming hormone therapy (GAHT) for a short period of time or a while, you may have started to notice some specific changes such as physical changes to your genitals (bottom growth), increase in sex drive, and/or changes to menstruation. While HRT may impact fertility, taking gender-affirming hormones does not automatically make someone infertile. For more information on how testosterone HRT affects fertility, read on.

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.

Testosterone can impact the menstrual cycle and therefore fertility.

When it comes to menstruation and ovulation, testosterone affects the way existing hormones function and this has an impact on both menstruation and ovulation. These changes can decrease a person’s level of fertility. The effect of testosterone on the uterus causes the lining to grow thinner which impacts monthly bleeding in that the lining doesn’t shed monthly in the same way it might have before testosterone (if a person wasn’t taking other hormonal birth control methods). This becomes noticeable as less bleeding during monthly bleeding. Over time, bleeding can become less frequent, if it occurs at all. While this is not a guarantee that menstruation will completely stop while on testosterone, some people do notice changes in their monthly bleeding. Of course, dosage, frequency, and length of time on HRT all affect the changes you might see in your menstrual cycles.

Testosterone can inhibit some of the other hormonal levels that trigger ovulation, making ovulation less predictable. Many peoples’ ovaries will release eggs less frequently, if at all. However, this doesn’t mean that ovulation entirely stops if someone is taking testosterone. This means that a person on T can still be fertile and get pregnant while on testosterone.

Pregnant transmasculine man

Can I still get pregnant if I’m on testosterone?

YES, pregnancy is absolutely still a possibility if you’re on testosterone. If you’re having sex without a condom where sperm from one person enters your vagina/front hole, then there is a chance that you can get pregnant. Just because someone with a uterus and ovaries is on testosterone doesn’t mean they are not ovulating/producing any eggs, even if that person is no longer menstruating. Even if you are sleeping with someone who is on estrogen HRT, there is still a chance that you might get pregnant if not using birth control. 

If you’re on hormone treatment but have undergone a hysterectomy, you won’t be able to get pregnant, as you no longer have a uterus to carry a pregnancy.

Can testosterone be used as birth control?

NO, testosterone is not a sufficient contraception method. If you want to continue having the type of sex where sperm enters your body without getting pregnant, you should explore birth control options. There are both non-hormonal and hormonal birth control options. Taking hormonal birth control with estrogen will not affect your testosterone transition. You can opt for methods such as condoms, the pill, or long-acting contraceptives such as an implant or an IUD.

Testosterone and pregnancy coexist in different ways.

While you can still get pregnant on testosterone therapy, if you wish to carry the pregnancy to term, you will need to stop hormone therapy altogether. Testosterone treatment isn’t safe for pregnancy and can cause problems for the pregnancy, fetus/baby. In this instance, finding an inclusive birth worker (obstetrician, doula, midwife, etc.) may be helpful to ensure sensitivity to gender throughout the pregnancy and birth process.

We also understand that pausing testosterone GAHT can be difficult and trigger gender dysphoria for many. Fortunately, there are fertility preservation options. Those who want to take testosterone and carry a pregnancy in the future can freeze eggs for use later, or otherwise stop taking testosterone and use their existing eggs. If someone on testosterone wishes to use their eggs to create a pregnancy but doesn’t wish to carry it, they can pursue alternative methods like in-vitro fertilization (IVF), with or without freezing their eggs, where a partner or surrogate carries the pregnancy.

Artificial insemination illustration

Do I have to freeze eggs before starting testosterone?

No, not necessarily: Freezing eggs can happen before or after beginning testosterone. FOLX Chief Clinical Officer and nurse practitioner Kate Steinle recommends the sooner, the better when it comes to egg storage.

“It’s best to store eggs at an earlier age,” explains Steinle. “Egg health is much higher in someone's 20s than in their 30s, and usually decreases substantially in their late 30s and 40s.”

However, testosterone isn’t the culprit here. “The a big decreaser is age, much more so than taking testosterone,” Steinle elaborates. “Sure, while someone is actively taking testosterone, there is often suppression of ovulation (release of eggs), which decreases someone's fertility dramatically since if they don't release an egg, they can't have that egg fertilized/create a pregnancy.” Adding testosterone to age can decrease fertility, but the long-term effects are less certain. 

Some transgender people choose to store their eggs for a future pregnancy before beginning testosterone both because of the impact of testosterone on fertility, as well as the simple fact that, for all genders, fertility is at its peak at younger ages. We recommend working with an LGBTQ+ competent healthcare provider, if possible or accessible when seeking fertility and family building services.

If you decide to freeze your eggs, the process entails first taking a series of synthetic hormones that stimulate the ovaries to produce multiple eggs (rather than the single egg that typically develops monthly), followed by a small surgical procedure typically under sedation to remove the eggs from the ovaries. A friendly reminder: egg storage can be an ongoing conversation for those who are currently fertile. If you aren’t sure whether you want to or not, you still have time to think—your biological clock isn’t the ticking time bomb that patriarchal narratives think it is.

Ovarian reserve tests can measure the quantity and quality of eggs in your ovaries, though understand that these tests aren’t completely accurate and therefore can be limiting. Egg freezing can certainly be done before beginning testosterone, but if you are looking to do so after beginning testosterone, whether or not you need to pause HRT will depend on how your body responds to the ovary-stimulating hormones. 

Once removed, the eggs can be stored either as just eggs (to be fertilized with sperm later) or as embryos (fertilized by sperm then stored as an embryo to be implanted later). The eggs or embryos are then stored at a fertility clinic for future use.

“The process of storing eggs is much more costly than the process of storing sperm,” explains Steinle. “For egg storage, the eggs need to be retrieved from your body, which requires medication to stimulate egg maturation, ultrasounds to monitor, and a procedure to remove the eggs from your body. All of this monitoring and treatment costs time and money.” At present, most insurances do not offer comprehensive coverage for fertility treatments. Medicaid—or public health insurance—has never covered fertility preservation. These policies demonstrate many of the implicit and explicit biases against people of low socioeconomic status in our country.

This all goes to say, family planning looks different for all kinds of trans and nonbinary people on testosterone. One of the beauties of queer families is that they can look many different ways. Many people on testosterone don’t end up carrying their own children, whether it’s by choice or because of health or systemic barriers. Know that carrying your own children is only one way to build a family and that many different opportunities and options are available to you.

Although FOLX currently doesn’t offer queer fertility services, we’d love to support you through the process. For FOLX members with further questions about testosterone and fertility options, consider scheduling an appointment with your clinician. For anyone who isn't a FOLX member, drop us a line at support@folxhealth.com.

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