Understanding Transgender Pregnancy

Transgender father and daughter on couch doing homework
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Many transgender men and women 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 who is not opposed to carrying a child and who has a cisgender male partner may be able to carry a child with relative ease.

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 or have a uterus.

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/gender
  • 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 Men and Childbearing

Transgender men are assigned female at birth. Most 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 has a cisgender female 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 has a cisgender male partner, things may simpler. They can potentially have a child that is biologically both of theirs and carried by the transgender partner to term.

Effect of Surgeries

If a transgender man has had a hysterectomy, either on its own or in preparation for a gender-affirming surgery such as phalloplasty or metoidioplasty, he can not carry a pregnancy. Since the ovaries are often removed at the time of a hysterectomy, transgender men 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 transgender men. A stimulated cycle can be very dysphoric and cause symptoms such as anxiety and depression.

Transgender men 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 transgender men 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.

Transgender Women and Childbearing

There is a somewhat common misconception that transgender women can get pregnant after undergoing a vaginoplasty. That is not accurate. In order for a transgender woman to become pregnant, she would have to have a uterus transplant.

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

Banking Sperm

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

However, where it is feasible, transgender women who are interested in having biological children are encouraged to bank sperm prior to medical transitioning. This is not generally possible for transgender women who transition prior to puberty. Still, as with transgender men, 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 for a transgender woman to make sperm.

In addition, some transgender women 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 has a cisgender female partner, they can have a child who shares both of their genes. The transgender woman can provide sperm and the cisgender woman can provide an egg and carry the pregnancy—or, they can use a surrogate.

If a transgender woman has a cisgender male 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, both transgender men and transgender women are capable of breastfeeding. This is because breast tissue is very similar in both men and women. 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 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 that people interested in transgender pregnancy 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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