Fertility conversations

Gender-affirming medical and surgical interventions can have temporary or permanent impacts on a client's fertility. Understanding how these interventions may impact fertility is an essential part of informed consent before beginning gender-affirming hormones or accessing certain gender-affirming surgeries.

The research around how gender-affirming hormones and surgeries impact fertility is a growing field. We recommend using this resource alongside WPATH Standards of Care 8 [1], recent scientific publications, and local care guidelines to facilitate fertility conversations.

WPATH Standards of Care 8

The World Professional Association for Transgender Health (WPATH) Standards of Care (8th ed.) recommend that all TTNB clients are aware of how gender-affirming treatments may impact their fertility and that fertility conversations should be ongoing throughout care. Their recommendations state:

“We recommend health care professionals who are treating transgender and gender diverse people and prescribing or referring patients for hormone therapies/surgeries advise their patients about: 

a. Known effects of hormone therapies/surgeries on future fertility;
b. Potential effects of therapies that are not well studied and are of unknown reversibility;
c. Fertility preservation (FP) options (both established and experimental);
d. Psychosocial implications of infertility”  [1, p. S159].

Fertility conversations should: 

• Introduce the topic of fertility in a gender-affirming and neutral way
• Create a space where clients feel safe asking fertility-related questions without fear of judgement or treatment being withheld
• Discuss fertility preservation but not present it as the only option for family creation
• Ensure clients are informed of short- and long-term impacts of proposed treatments on fertility
• Present available evidence on risks and benefits of treatments and alternatives
• Include the approximate costs of fertility preservation

Fertility conversations may occur before accessing gender-affirming treatments for the first time, when considering changing the plan of care (e.g., when considering gender-affirming surgery), or at any other point during care provision. These conversations should be introduced as soon as possible during readiness planning or gender-affirming care planning [1]. This ensures that clients have adequate time to consider their options before planned treatments or surgeries.

Providers do not need to be experts in fertility care to begin conversations about fertility and, where appropriate, fertility preservation. Primary care providers are well situated to answer client’s initial questions, explore fertility goals, and provide additional resources or fertility information.

In most cases, fertility conversations extend over multiple appointments as clients consider their options and review any decision support tools [2]. Fertility conversations can be returned to when clients have questions or their fertility goals change. As clients build comfort with providers, they may be more willing to share what they are thinking and engage in open communication [3].

Healthcare providers who are providing gender-affirming care should be familiar with basic fertility related concepts. This includes: 

• An overview of how the chosen intervention can impact fertility

• Options for fertility preservation and how individual factors may influence these options

• When to refer to a fertility specialist or higher level of care

Reflective practice 

Fertility conversations can be influenced by a provider's unconscious beliefs or bias. Without questioning this bias, providers may be engaging in gatekeeping behaviours. Ideas about family creation that are based in a heteronormative model (i.e., having genetically-related offspring within a heterosexual marriage) cause harm to TTNB clients [3,4].

Fertility conversations can be difficult or uncomfortable for clients. Factors that may increase this discomfort include:

Removing gendered connotations, framing genetic parenthood as one of many options for creating a family, and reframing the conversation as an opportunity to reflect on future goals can be helpful to ease this conversation [3,4]. While integrating other family creation options into fertility conversations is important, providers who do not include fertility preservation as an option may be seen as a barrier for clients who want to explore this [5].

Supporting informed choice requires providers to reflect on their beliefs around parenting and family creation, ensuring that these ideas (whether for or against) do not seep into their fertility conversations with clients. Reflecting on previous fertility conversations can help providers increase their comfort with future ones [3].

Using the shared decision-making model, adapted from Elwyn et al. [6], fertility conversations should include different ways to build a family, provide evidence-based information, avoid gendered assumptions about parenting, and centre the client's context.

Choice talk

Choice talk introduces the fertility conversations and outlines the decisions that need to be made. Choice talk should acknowledge the role of uncertainty and introduce a variety of options for family creation. 

Option talk 

Option talk reviews how hormones or surgery may impact fertility and options for care. Option talk should list options for fertility preservation and consider the benefits, risks, and alternatives. 

Decision talk

Decision talk encourages the client to choose the fertility option that is the best fit for them at this point in their life. After discussing the options for care, offering decision support tools, and providing time for deliberation, check if the client is ready to decide. If they are not ready to decide, ask if they need more time, information, or a referral to a fertility specialist.

For more information about how shared decision making can be applied to fertility conversations, see Trans Care BC’s course, Fertility conversations in gender-affirming care.

The following sections outline the key topics to address during fertility conversations, tailored to the client’s medical history, personal context, and goals. The cost of fertility preservation and fertility treatments, detailed below, should also be included in these conversations. 

Anatomical and hormone inventory

Taking an anatomical and hormone medication inventory ensures that clients get appropriate care based on the organs they have and hormones they take. Using gender and/or sex assigned at birth to guide care can lead to misgendering, client harm, missed or incorrect health screening, and administrative errors [7].

For more information about taking an anatomical and hormone inventory, see the Gender-affirming approach to physical exams clinical handbook section. 

Age

When discussing fertility, consider how a client's age may influence their preservation options and the time they have to make a decision.

The role of uncertainty

It is important to review the role that uncertainty plays in fertility discussions. Infertility is a common experience: worldwide, roughly one in six people will experience infertility in their lifetime [10]. There is no way to know what a client's future fertility will entail or if fertility preservation measures will result in a pregnancy that ends with a live birth. Recognizing and communicating this uncertainty supports clients in making informed decisions.

Options for becoming a parent 

There are many pathways to parenthood. Some include biological children (e.g., pregnancy, IVF with own eggs or sperm) and others do not (e.g., adoption, step-parenting, IVF with egg or sperm donation). During fertility conversations, it is important to explore the full range of options available.

Options for becoming a parent is an info chart created in 2015 by Chris Veldhoven to detail the many different ways that families can be created. He created it while facilitating workshops through the LGBTQ Parenting Network, a program of Sherbourne Health that supports lesbian, gay, bisexual, trans and queer parenting. This resource may help clients reflect on the different possibilities and determine what feels right for them.

Decision support tools

Offer decision support tools, such as priority setting tools or an overview of biological reproduction, to assist clients in making informed choices. These resources can help clarify options, facilitate future discussions and support decision-making. See below for resources from Rainbow Health Ontario.

Concluding the conversation

Due to the many factors that influence fertility decisions, clients may have a wide range of feelings about their fertility and resulting decision(s), including joy, ambivalence, or grief. Emotions about the decision are not an indicator that they have made the wrong decision or are not ready to decide. Fertility decisions are highly personal and there is no one right choice for everyone.

Finish the conversation by summarizing the choice made and encouraging clients to return to this conversation at any time. Ask if they are comfortable with periodic check ins about their fertility or family planning goals on an ongoing basis. Ensure there is a detailed record made of the conversation and the decision made.

The cost of fertility preservation plays a significant role in the fertility decisions clients make. TTNB people are more likely to choose fertility preservation in areas where it is publicly funded [11].

Costs of fertility preservation include:

Some clients may have to decide between the cost of fertility preservation and the costs associated with having gender-affirming surgeries (e.g., travel, accommodations, time off work).

Funding in BC

Within British Columbia, fertility clinics are located within the private healthcare system. This means that most fertility care, including fertility preservation and storage fees, need to be paid for by the client or their private insurance plan.

Initial consultations (including most bloodwork and tests) are covered by BC's medical services plan (MSP) with a referral from a primary care provider. Referral procedures will differ based on community and fertility clinic. Appointments may be available virtually. In some cases, clients may need to wait longer for an MSP funded referral.

A new publicly funded in-vitro fertilization (IVF) program began in July 2025. It will fund up to $19,000 for one cycle of IVF per lifetime. This includes the cost of egg retrieval for the purposes of IVF but does not include fertility preservation or storage fees.

For more information, see the Government of BC’s website: Publicly Funded IVF Program

Fertility preservation in BC: Sample collection and storage

The following numbers are provided as general estimates to help guide fertility conversations and have been gathered from fertility clinic websites. Clients who want an individualized treatment plan (including costs) should be encouraged to talk to a fertility clinic and offered a referral for a fertility consultation.

After fertility preservation, further fertility treatments will be required to achieve pregnancy. Potential treatments and costs include: 

Fertility conversation documentation, completed after every client interaction, should include the following components:

• Date
• Who was present for the conversation
• Topics reviewed
• Personal family planning goals, including quotes where possible
• Accepted or declined fertility clinic referral
• Any other important information that came up
   

Fertility conversations should be tailored to each client’s context. For additional guidance, consult the following sections of the Trans Care BC Clinical Handbook: 

• Fertility conversations with people who produce sperm
• Fertility conversations with people who produce eggs

1. Coleman E, Radix AE, Bouman WP, Brown GR, De Vries ALC, Deutsch MB, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022;23: S1–S259. doi:10.1080/26895269.2022.2100644

2. Stanley JR, Ratnapalan S. Patient education and counselling of fertility preservation for transgender and gender diverse people: A scoping review. Paediatrics & Child Health. 2024;29: 231–237. doi:10.1093/pch/pxad050

3. Lai TC, Davies C, Robinson K, Feldman D, Elder CV, Cooper C, et al. Effective fertility counselling for transgender adolescents: A qualitative study of clinician attitudes and practices. BMJ Open. 2021;11: e043237. doi:10.1136/bmjopen-2020-043237

4. Clark BA. Narratives of regret: Resisting cisnormative and bionormative biases in fertility and family creation for transgender youth. IJFAB: International Journal of Feminist Approaches to Bioethics. 2021;14: 157–179. doi:10.3138/ijfab-14.2.09

5. Bartholomaeus C, Riggs DW. Transgender and non-binary Australians’ experiences with healthcare professionals in relation to fertility preservation. Culture, Health & Sexuality. 2020;22: 129–145. doi:10.1080/13691058.2019.1580388

6. Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: A model for clinical practice. J GEN INTERN MED. 2012;27: 1361–1367. doi:10.1007/s11606-012-2077-6

7. Clark DBA, MacNeil L, Grieves L, Townsend M. Gender and sex data practices within electronic health records in a primary care setting: A use case approach. Canadian Journal of Nursing Informatics. 2022;18: 1–23. 

8. Saumet J, Petropanagos A, Buzaglo K, McMahon E, Warraich G, Mahutte N. No. 356-Egg freezing for age-related fertility decline. Journal of Obstetrics and Gynaecology Canada. 2018;40: 356–368. doi:10.1016/j.jogc.2017.08.004

9. Johnson SL, Dunleavy J, Gemmell NJ, Nakagawa S. Consistent age-dependent declines in human semen quality: A systematic review and meta-analysis. Ageing Research Reviews. 2015;19: 22–33. doi:10.1016/j.arr.2014.10.007

10. World Health Organization. Infertility prevalence estimates, 1990-2021. 1st ed. Geneva: World Health Organization; 2023. Available: https://www.who.int/publications/i/item/978920068315

11. Stolk THR, Asseler JD, Huirne JAF, van den Boogaard E, van Mello NM. Desire for children and fertility preservation in transgender and gender-diverse people: A systematic review. Best practice & research Clinical obstetrics & gynaecology. 2023;87: 102312. doi:10.1016/j.bpobgyn.2023.102312