Fertility conversations with people who produce eggs
Disclaimer
The purpose of this content is to provide health care professionals with key messages and evidence-informed recommendations for gender-affirming care in British Columbia (BC). This content was developed by provincial subject matter experts. The review process involved an internal evaluation by interdisciplinary healthcare professionals at Trans Care BC, as well as an external review conducted by additional interdisciplinary healthcare professionals and community members from across the province.
This content reflects the best available knowledge and resources at the time of publication. Trans Care BC documents are intended to provide information, education, and guidance only and should not be used as a substitute for clinical judgement and assessment of the individual needs of transgender, Two-Spirit, and non-binary people. Health care professionals should continue to exercise clinical judgement and take into consideration context, resources, wise practices, and other relevant factors when providing gender-affirming care.
Provincial Health Services Authority (PHSA) and Trans Care BC are not liable for any damages, claims, liabilities, costs, or obligations arising from the use of this document including loss or damages from any claims made by a third party. PHSA and Trans Care BC also assume no responsibility or liability for changes made to this document without their consent.
A growing body of evidence demonstrates that taking testosterone does not impair internal gonad (ovarian) function, although long term research is limited [1]. People who produce eggs can choose to preserve their fertility before beginning testosterone or can pause testosterone at a later date to retrieve gametes (eggs) or pursue pregnancy.
Reproduction in people born with internal gonads (Ovaries)
People who are born with internal gonads (ovaries) are born with all of their gametes (oocytes; immature eggs). Beginning at puberty, oocyte maturation begins, driven by the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) [1,2]. Mature oocytes (ovum or eggs) are released during ovulation every 24-35 days until menopause [2].
Puberty Suppression
Puberty suppression medications suppress the release of FSH and LH, preventing ovulation and blocking unwanted estrogen-based pubertal changes. This allows time for youth to mature and for the youth and family to make decisions about further medical intervention. Stopping puberty suppression results in the return of ovulation and, when used as a treatment for precocious puberty in cisgender youth, long term studies show normal ovarian function, conception rates, and pregnancy outcomes [1].
For more information about puberty suppression, see Puberty suppression (under development).
Testosterone
Gender-affirming testosterone therapy suppresses the release of FSH and LH and increases the circulating levels of testosterone. In many (but not all) cases, this temporarily suppresses ovulation. Current evidence suggests that taking testosterone does not impair ovarian function [1].
Because gender-affirming testosterone therapy suppresses but does not block the release of FSH and LH, ovulation may still occur. Testosterone is considered teratogenic and birth control should be used by clients who are taking testosterone and engaging in sexual activity that could result in pregnancy [3,4].
Hysterectomy
Gender-affirming surgery may include a hysterectomy with or without an oophorectomy. Clients who have a hysterectomy will not be able to get pregnant, however, retaining the ovaries is an option for fertility preservation [5]. In many cases, clients who retain their ovaries can have a biologically related child by utilizing IVF but another person (e.g., partner, co-parent, surrogate) would need to gestate the pregnancy. It is important to note, however, that all surgeries can have unexpected complications and success of oocyte retrieval after a gender-affirming hysterectomy has not been studied.
Oocyte retrieval and freezing is the most common form of fertility preservation for people with internal gonads (ovaries). Experimental options include ovarian tissue freezing and in vitro maturation of an immature oocyte [1]. Ovarian tissue freezing has only been successful in autologous transplantation, which may not be desirable for TTNB people. In vitro maturation (IVM) of ovarian tissue has not yet led to a successful pregnancy [1].
Oocyte retrieval is an invasive procedure. Clients who are considering fertility preservation should be aware that oocyte retrieval includes frequent (often internal) ultrasounds, daily hormones, and transvaginal oocyte retrieval. Retrieval is typically done under sedation [4].
In most cases, stopping gender-affirming medications results in the return of ovulation, although long-term impact of testosterone on ovarian health is understudied [4]. Stopping puberty suppression medications or testosterone will result in the development or return of estrogen dominant features that may not be desirable, including monthly bleeding.
Due to concerns of impaired fertilization of testosterone-exposed oocytes, it is recommended to stop testosterone three months before attempting to become pregnant or harvesting oocytes for fertility preservation [4]. A small number of studies have shown oocyte retrieval can be successful when people continue to take testosterone [6,7].
A retrospective cohort study of 50 fertility preservation cycles in transmasculine and non-binary patients found no difference in the number of oocytes retrieved or mature oocytes in patients who had taken testosterone and those who had not [8].
Successful pregnancy after oocyte retrieval is related to multiple factors, including age when eggs are retrieved. In cisgender women, the oocyte-to-baby/live birth rate is around 20 oocytes, but this has not been studied in TTNB people [4]. For some people, multiple oocyte retrievals will need to be completed to reach this number [4].
For a large systematic review on fertility decision making and fertility preservation, see Stolk et al. (2023). Desire for children and fertility preservation in transgender and gender-diverse people: A systematic review.
For clinical recommendations from the above review, see Stolk et al. (2023). Fertility counseling guide for transgender and gender diverse people.
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
Danhausen K, King TL. Anatomy and physiology of pregnancy. 7th ed. In: Phillippi J, Kantrowitz-Gordon I, editors. Varney’s midwifery. 7th ed. [S.l.]: Jones & Bartlett Learning; 2023.
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
Stolk THR, Van Den Boogaard E, Huirne JAF, Van Mello NM. Fertility counseling guide for transgender and gender diverse people. International Journal of Transgender Health. 2023; 1–7. doi:10.1080/26895269.2023.2262460
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
Greenwald P, Dubois B, Lekovich J, Pang JH, Safer J. Successful in vitro fertilization in a cisgender female carrier using oocytes retrieved from a transgender man maintained on testosterone. AACE Clinical Case Reports. 2022;8: 19–21. doi:10.1016/j.aace.2021.06.007
Stark BA, Mok-Lin E. Fertility preservation in transgender men without discontinuation of testosterone. F&S Reports. 2022;3: 153–156. doi:10.1016/j.xfre.2022.02.002
Raj-Derouin N, Ben-Ozer S, Dhesi AS, Harrison TNh, Ghahremani M, Jabara SI, et al. Prior testosterone use does not appear to impact oocyte cryopreservation outcomes in transgender patients: Findings from a multicenter health maintenance organization. Fertility and Sterility. 2024;122: e12–e13. doi:10.1016/j.fertnstert.2024.07.100
| Current version | Sept 16, 2025 | |
| Authors | Elijah Foran | Knowledge Translator, Trans Care BC |
| Caitlin Botkin | Nurse Educator, Trans Care BC; Registered Midwife (non-practicing) | |
| Lauren Goldman | Nurse Educator, Trans Care BC; RN(C) | |
| Contributors | Ingrid Cosio | Medical Director, Trans Care BC |
Disclaimer
The purpose of this content is to provide health care professionals with key messages and evidence-informed recommendations for gender-affirming care in British Columbia (BC). This content was developed by provincial subject matter experts. The review process involved an internal evaluation by interdisciplinary healthcare professionals at Trans Care BC, as well as an external review conducted by additional interdisciplinary healthcare professionals and community members from across the province.
This content reflects the best available knowledge and resources at the time of publication. Trans Care BC documents are intended to provide information, education, and guidance only and should not be used as a substitute for clinical judgement and assessment of the individual needs of transgender, Two-Spirit, and non-binary people. Health care professionals should continue to exercise clinical judgement and take into consideration context, resources, wise practices, and other relevant factors when providing gender-affirming care.
Provincial Health Services Authority (PHSA) and Trans Care BC are not liable for any damages, claims, liabilities, costs, or obligations arising from the use of this document including loss or damages from any claims made by a third party. PHSA and Trans Care BC also assume no responsibility or liability for changes made to this document without their consent.