Understanding Transgender Pregnancy

Many transgender people are interested in having biological children. How easy or difficult it depends on a number of factors. For example, it is far more difficult to save gametes for eventually assisted reproduction for people who medically transition before puberty. On the other hand, a transgender man or transgender non-binary person who is not opposed to carrying a child and who has a partner with a penis may be able to carry a child with relative ease.

Transgender father and daughter on couch doing homework
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Sexual Reproduction 101

With the exception of certain individuals who are born with disorders of sexual differentiation, sperm can only be retrieved from individuals who are assigned male at birth. In contrast, only people who are assigned female at birth can make eggs.

Therefore, in order to make a baby, you need genetic contributions from at least one person assigned male at birth and one assigned female at birth. You also need an assigned female with a functional uterus who can carry that infant to term.

Couples trying to conceive do not always have access to everything they need to make a baby. They may need donated eggs or sperm if they only have one or the other. They may also need to find a surrogate (an assigned female who carries a baby) to carry their child if they live in a place where doing so is legal.

Factors Affecting Transgender Reproduction

Factors that affect the complexity of being able to have biological children for someone who is transgender include:

  • Their assigned sex at birth
  • If, when, and how they medically transition
  • If, when, and how they surgically transition
  • Whether they have used fertility preservation techniques to store gametes (sperm/eggs)
  • Their partner's sex
  • Their access to insurance coverage for assisted reproduction or their ability to pay out-of-pocket for fertility care
  • Local laws around assisted reproduction, surrogacy, and related concerns

Transgender People and Childbearing

Transgender men and some non-binary people are assigned female at birth, meaning they are born with ovaries and a uterus. This means that they are capable of becoming pregnant and carrying a pregnancy to term. Transgender pregnancy is not very common, but it has been shown to be safe for both the parent and the baby.

Testosterone therapy usually leads to anovulation and amenorrhea (when the ovaries stop releasing eggs during a menstrual cycle and when the menstrual cycle stops). Stopping testosterone therapy may or may not reverse the effects, thus it can potentially affect fertility.

If a transgender man or non-binary person assigned female at birth has a cisgender woman as a partner, either of them can potentially carry their child. However, the couple will need donor sperm in order to become pregnant.

If a transgender man or non-binary person assigned female at birth has a cisgender man as a partner, things may simpler. They can potentially have a child that is biologically both of theirs and carried by the transgender partner to term.

This is also possible if the partner of a transgender man or non-binary person assigned female at birth is a transgender woman or non-binary transfeminine person. However, the chance of successful conception will be influenced by aspects of both of their transitions.

Effect of Surgeries

If a transgender man or non-binary person assigned female at birth has had a hysterectomy, either on its own or in preparation for a gender-affirming surgery such as phalloplasty or metoidioplasty, they can not carry a pregnancy. Since the ovaries are often removed at the time of a hysterectomy, they should consider egg retrieval if they may wish to have biological children in the future.

However, since egg retrieval usually requires a stimulated cycle, this option may not be acceptable to some. A stimulated cycle can be very dysphoric and cause symptoms such as anxiety and depression.

Transgender men and non-binary people assigned female at birth may also be encouraged to store eggs prior to any medical transition. This also requires a stimulated cycle. Standard pathways of egg banking are not generally an option for those who transition prior to puberty.

However, some researchers and doctors are exploring experimental oncofertility (cancer fertility) techniques to retrieve gametes in individuals who transition early.

These techniques were designed to help children with cancer preserve their fertility in the face of treatments that would otherwise damage or destroy their ability to reproduce.

Transfeminine People and Childbearing

There is a somewhat common misconception that transgender women and transfeminine people can get pregnant after undergoing a vaginoplasty. That is not accurate. In order for someone in this group to become pregnant, she would have to have a uterus transplant.

This is not a surgical option that is currently available for this population. (There have been reports of a cisgender woman with MRKH giving birth after a uterus transplant.)

Banking Sperm

Transgender women and transfeminine people can, however, contribute sperm to a pregnancy. Some bank sperm prior to any medical transition. This is much more straightforward than the procedure for banking eggs. They may also be able to produce and retrieve sperm while on hormones, either through ejaculation or testicular sperm extraction.

However, where it is feasible, those in this population who are interested in having biological children are encouraged to bank sperm prior to medical transitioning. This is not generally possible for those who transition prior to puberty. Still there are some experimental techniques for gamete harvesting under development.

If sperm banking is to be done, it must be done before vaginoplasty.

During vaginoplasty, the testes are removed. After this point, it is not possible to make sperm.

In addition, some transgender women and transfeminine people have an orchiectomy to remove their testicles without vaginoplasty. This allows them to reduce the intensity of their cross-sex hormone therapy. Sperm banking must be done before orchiectomy as well.

If a transgender woman or transfeminine person has a partner assigned female at birth, they can have a child who shares both of their genes. The transgender woman or feminine person can provide sperm and the partner assigned female at birth can provide an egg and carry the pregnancy—or, they can use a surrogate.

If a transgender woman has someone assigned male at birth as a partner, only one of them will be able to contribute their genes to a child. They will need to use a donor egg and have a surrogate carry the pregnancy.

Transgender Breastfeeding

Breastfeeding can be a very meaningful way of connecting to your child. Theoretically, all trans people are capable of breastfeeding. This is because breast tissue is very similar across gender. Stimulating milk production just requires the right combination of hormones.

In 2018, scientists published the first report of a transgender woman successfully nourishing a child through stimulated lactation.

Transgender men and non-binary people assigned female at birth who intend to chest-feed a child may wish to either postpone chest reconstruction or discuss nipple-preserving options with their surgeon.

A Word From Verywell

Regardless if a transgender person chooses to have children biologically, to adopt, or to not have children at all, it's important to know what is and isn't possible. Discussions about fertility should be an important part of transition care. When someone wants to preserve fertility, it may be easier to do so earlier on. It is important to note that people have very different priorities around balancing the urgency to transition with any desire to have children. Some people put pregnancy above all else. Others put transition first and foremost. There is no one pathway to an affirmed life or successful parenthood.

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