Assisted reproduction treatment for transsexual patients

Reproductive health includes an individual’s right to conceive and the right to decide when to do so. As we have previously pointed out, when speaking about reproduction in 2016, the World Health Organization recognised the term ‘structural infertility’ with a view to fomenting everybody’ opportunity to realise their plan to raise a family, irrespective of biological impediments and thanks to reproductive technology.

Gender-affirming pharmacological treatment can decrease a person’s chances of reproducing, even if there has been a washout period after interrupting hormone blocking treatment for the biological sex assigned at birth.

With regards to surgical treatment, an orchiectomy (removal of the testes) or oophorectomy (removal of the ovaries) means that gametes (spermatozoa or ova) can no longer be obtained from the patient unless steps to preserve them were taken beforehand (freezing spermatozoa/testicular biopsy and oocyte vitrification/ova freezing). More information about this can be accessed in another publication. Hysterectomies (removal of the uterus) mean that gestation is no longer possible for trans males.

Bearing the aforementioned in mind, let us take a schematic look at the options that are available for so that people can form a family. We will presume that at least one of the parties involved has an initial preference for genetic filiation.

Assisted reproduction treatment for trans women

Reproduction techniques for single women

In this case, the options come down to surrogate pregnancy, which is not legal in Spain.

With regards to semen, it can be obtained from ejaculate following a washout period of between 3 and 24 months after ceasing to take oestrogen treatment.

If the patient has previously undergone sperm or testicular preservation treatment, this is an option that avoids the stress of interrupting treatment or retrieving the sample. It can also be put to use if obtaining a sample from the ejaculate or by means of testicular puncture/biopsy has proved impossible.

If retrieving a semen sample from the patient is not possible, then a sperm donation can be used.

With regards to the oocytes, they can be received from a donor.

Assisted reproduction treatment if the partner is female

If the patient’s partner is a cisgender person, then the partner’s oocytes can be used.

If the patient has not had external genital surgery and the trans male can produce spermatozoa, the option of natural sexual intercourse still exists. However, a recent study discusses abnormal semen samples in trans women, making them suitable for ICSI even before starting hormone treatment. If this is the case, the female partner can have ovarian stimulation treatment to retrieve oocytes and have them microinjected with the partner’s semen if possible or, alternatively, donor semen can be used. Following this, the embryos can be transferred to the partner’s uterus for gestation.

If retrieving oocytes is not possible (for example, due to advanced age or poor ovarian reserve that does not respond to treatment), then ova donation (egg donation) can be attempted.

Assisted reproduction treatment if the partner is male

Once again, this situation presents us with the couple’s inability to gestate and surrogate pregnancy is therefore the available option.

With regards to the origin of the gametes, if it is not be possible to retrieve spermatozoa from the trans woman, it might be possible to retrieve them from the cisgender male partner.

Should all attempts fail, the last option is in vitro fertilisation treatment with dual gamete donation.

Other possible options for reproduction

The concepts of reproductive medicine as a technology and biohacking can take our imagination on a journey far beyond what is actually currently possible.

To give a more specific example, men have not yet undergone uterus transplants in order to gestate. Everything is possible in medicine, but the fact that other alternatives (surrogacy) exist means that this is unlikely to become a reality.

Assisted reproduction treatment for trans men

If the patient is single

In terms of oocytes, they could be retrieved from the patient. A testosterone washout period of between 3 and 6 months does suggest that normal ovarian function and menstruation can be retrieved. If this is the case, intrauterine insemination can be attempted if appropriate conditions are met. However, it is not perhaps the most recommendable option. The best option is ovarian stimulation to retrieve oocytes that can later be microinjected (ICSI) with donor sperm as part of in vitro fertilisation treatment. The embryos that are generated are transferred to the patient’s uterus, which has previously been readied, ideally one embryo at a time.

If oocytes have not previously been preserved and obtaining them is impossible, dual donation can be selected for prospective embryo transfer to the patient following preparation of the endometrium.

If the partner is female

If the patient’s partner is a cisgender woman, there are a range of possibilities if both individuals are able to produce oocytes and gestate. Perhaps the ROPA method is the most accepted of them all. It offers couples a unique opportunity to share the process from a medical and emotional point of view. It involves the male trans patient donating ova, either following stimulation or by defrosting oocytes that had previously been retrieved. These are then fertilised using donor sperm. The resulting embryos are transferred, preferably one at a time, to the cisgender female partner who has been readied to receive the embryo following a period of endometrial preparation.

It may be possible to manage the timing in this case and do everything in a synchronised manner using fresh embryos. Alternatively, it is possible to make the most of the time that freezing (vitrification) provides, defrosting oocytes and embryos in our laboratory.

It may also be possible for the male trans partner to gestate and this option has recently gained greater visibility.

Assisted reproduction treatment if the partner is male

In this case, the cisgender male can donate spermatozoa, which can be used to fertilise ova so that the male trans patient can continue with the pregnancy.

Even if natural conception is possible, opting directly for ovarian stimulation for ICSI tends to be the better option if we take into account ovarian function following hyperandrogenism.

Instituto Bernabeu: personalised guidance for forming a family

We want you to rest assured that you can come to us and ask any questions you may have.

The field of reproductive technology provides us with many different options for making dreams of having a family come true. There are increasingly fewer biological barriers to having offspring and the huge progress that has been made in assisted reproduction laboratory processes, particularly in gamete (ova and spermatozoa) freezing techniques and in techniques for freezing ovarian tissue, means that being who you want to be does not imply giving up on the idea of having a family.

Last of all, it is important to point out the legal privileges we enjoy in Spain where we can all be who we want to be and have the family we choose to have.

Dr Cristina García-Ajofrín, gyneacologist at Instituto Bernabeu