Fertility conversations with people who produce sperm
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.
Most gender-affirming hormone medications for people who make sperm will impair or stop spermatogenesis (the production of sperm). Clients who want biologically related children should consider fertility preservation before initiating gender-affirming hormone medications or gonadectomy surgery [1,2].
Reproduction in people with external gonads (testes)
In people who are born with external gonads (testes), spermatogenesis begins at Tanner stage 3 or 4 of puberty. Driven by testosterone, it takes approximately 90 days for a germ cell to become mature sperm. After puberty, spermatogenesis is ongoing throughout the lifespan, although the quality of semen decreases with age [3].
For an overview of the key components of fertility conversations, see the Fertility conversations section of the clinical handbook.
Puberty suppression
Puberty suppression medications temporarily stop unwanted testosterone-based pubertal changes to allow time for youth to mature and for the youth and family to make decisions about further medical intervention. These medications can be initiated as early as Tanner stage 2. At this point, spermatogenesis has not yet begun and options for fertility preservation are limited to experimental tissue cryopreservation [4].
Puberty suppression is reversible and can be stopped to allow spermatogenesis to begin. The time required for spermatogenesis to begin is not clear and can vary considerably from one person to another [1].
For more information about puberty suppression, see Puberty suppression (under development).
Estrogen-based hormone therapy
Gender-affirming estrogen-based hormone medications lower circulating testosterone to levels similar to a cisgender woman [2,4]. Low levels of testosterone impair spermatogenesis and, over time, will lead to atrophy of external gonads [2]. The permanent impacts on fertility are unclear, with inconsistent research findings on restoration of fertility upon stopping estrogen-based hormone medications [2].
Orchiectomy
If clients do not preserve their fertility before an orchiectomy, having biologically related children is not possible.
Freezing sperm is the only proven fertility preservation option at this time as testicular tissue cryopreservation remains experimental [1]. To freeze sperm, a sample is collected through masturbation or testicular sperm extraction (TESE). TESE can be used by those who are unable to masturbate due to gender dysphoria or other limitations and may offer an alternative collection method for those with non-obstructive azoospermia [4]. TESE is likely possible once a client reaches Tanner stage 3-4 and has a testicular volume of greater than 10 mL [1].
For clients with non-obstructive azoospermia, TESE can be targeted towards tubules that have a higher concentration of mature sperm [5]. For TTNB clients planning to have TESE done, advise them to avoid or decrease lifestyle factors that impact semen quality (see below) for three months prior [4].
Semen quality and lifestyle factors
Semen quality may be impaired by TTNB specific lifestyle factors (e.g., low masturbation frequency, tucking, wearing tight undergarments). Low semen quality may decrease the chances of successful fertility preservation or achieving an eventual pregnancy. If semen quality is low, discuss avoiding (or decreasing) tucking for a period of three months before obtaining a new sample [1,2].
After stopping estrogen-based hormone medications, research studies report a wide range of time before spermatogenesis is (re)established, taking anywhere from 3-18 months, with some never achieving spermatogenesis [2,4]. A semen analysis can be considered every three months after stopping medications to determine when spermatogenesis is reestablished [4].
Stopping puberty suppression or estrogen-based hormone medications will result in the development or return of testosterone dominant features that may not be desirable.
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, 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
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
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
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
Tharakan T, Luo R, Jayasena CN, Minhas S. Non-obstructive azoospermia: Current and future perspectives. Fac Rev. 2021;10. doi:10.12703/r/10-7
| Current version | September 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 |