Fertility preservation prior to gender reassignment: a guide for GPs
Fertility care for transgender and gender-diverse patients is one of the most rapidly evolving areas of reproductive medicine - and one where GPs are increasingly called upon to provide guidance, support and timely referral. Gender-affirming hormone therapy and surgical interventions can have significant and sometimes irreversible effects on fertility, and many patients are making decisions about these treatments at a young age, often before they have given full consideration to their future reproductive options.
The conversation is nuanced, the clinical landscape is still developing, and it is understandable that many GPs feel uncertain about how to approach it. In this episode of Fertility in General Practice, Dr Monique Atkinson - Medical Director at Genea Bella Vista, CREI subspecialist, and paediatric and adolescent gynaecologist - joins host Dr Ali Hodgkinson to give GPs a practical framework for supporting transgender and gender-diverse patients through fertility preservation decisions.
Why fertility preservation matters in this context
Gender-affirming hormone therapy - testosterone for transgender men, oestrogen and anti-androgens for transgender women - affects reproductive function in ways that may be partially or fully reversible, depending on the duration of treatment and the individual. However, the extent of reversibility is not reliably predictable, and patients who wish to have biological children in the future should be informed of fertility preservation options before starting hormone therapy.
Surgical interventions - including gonadectomy (removal of the ovaries or testes) - result in permanent loss of the ability to produce gametes. These are irreversible decisions with direct implications for future fertility, and fertility preservation prior to surgery is the only way to retain the option of a biological child using the patient's own eggs or sperm.
The key principle for GPs is that these conversations need to happen early - ideally before any gender-affirming treatment begins - not because fertility preservation is the right choice for every patient, but because every patient deserves the opportunity to make an informed decision before options are closed off.
Fertility preservation options by pathway
For transgender women (assigned male at birth) considering gender-affirming hormone therapy or surgery, sperm banking before treatment begins is the most straightforward option. Sperm cryopreservation is a relatively simple process and can be arranged promptly. If a patient has already commenced hormone therapy, semen quality may be reduced but banking may still be possible - a fertility specialist review is warranted.
For transgender men (assigned female at birth), the options are more complex. If the patient has not yet commenced testosterone therapy, egg freezing or embryo freezing can be undertaken using a standard ovarian stimulation protocol. For those already on testosterone, stimulation may still be possible, though the protocol may need to be modified and the patient may need to pause hormone therapy temporarily - a decision that carries its own emotional and practical weight and must be handled with care.
For adolescent patients who are considering puberty suppression or early gender-affirming treatment, the fertility preservation conversation is particularly important and particularly sensitive. Options may include gonadal tissue cryopreservation, which remains an emerging technology, or fertility preservation prior to any hormonal intervention. Dr Monique Atkinson's dual expertise as both a CREI subspecialist and a paediatric and adolescent gynaecologist makes her exceptionally well-placed to discuss this area.
