Future Planning: a practical guide to fertility and gender-affirming hormones in the UK

By: Dr Rhy Brignell

Dr Rhy Brignell BA MA Ph.D

Rhy is Director of Service Delivery at Eden New Life and is responsible for ensuring all of our subscribers get fast, high quality care in accordance with our treatment protocols. They hold a PhD from the University of East Anglia and have specialised in gender services for more than 4 years, managing and advising on service delivery for thousands of patients. This is one of a series of articles where Rhy shares guidance and ideas with our members.

The question of what to do about fertility when we want to pursue gender-affirming hormone treatment can be a very difficult and personal one. It can be really hard to think about whether we may or may not want to have children in some nebulous far-off future, when we overwhelmingly want to start gender-affirming treatment as soon as possible in the present. In this article, I’ll cover some potential effects of hormone treatment that can impact fertility, as well as the basics of what preservation entails and the options available to you.

Will hormones affect my fertility?

The long-term effects of gender-affirming hormones on fertility are not clear, as there is a lack of long-term scientific data. However, we do know that taking testosterone impacts fertility as it generally suppresses the ability to produce eggs and changes the uterine environment. We also know that taking oestrogen impacts fertility as it generally suppresses the ability to produce sperm and causes testes to shrink. However, we don’t know to what degree this affects everyone, and there are differences in individual outcomes.

Generally speaking, the longer you have been on hormone treatment, the more likely it is that your fertility will be permanently impacted, and over time you may lose your ability to produce viable eggs or sperm entirely.

There is a possibility that stopping hormone treatment after you’ve already started could lead to fertility returning, but there just isn’t enough data out there to reliably advise on this. This is why clinicians want us to really think about our preservation options so that we can make an informed decision before starting gender-affirming treatment.

Do I still need to use contraception?

Yes - gender-affirming hormones are not contraception. Even though hormones are likely to affect your fertility, you could still be producing viable eggs or sperm, so it’s important to still use contraception.

It’s also worth noting that if you are taking testosterone and fall pregnant, you must stop testosterone as it can adversely affect the development of the foetus.

What does preservation entail?

If you want children in the future, or just want the option open to you, you may wish to preserve your fertility by having your sperm or eggs frozen and stored until you’re ready to use them. The ideal time to do this is before you’ve started any gender-affirming hormone treatment. You can still preserve after you have started hormones, but you’ll likely need to stop your hormones for a while, and there is no guarantee that the hormones won’t have already impacted your fertility. If you are considering stopping, always speak with your health provider (or Eden New Life specialist) beforehand.

Before you undertake any preservation procedures, you will be screened for various infectious diseases and genetic conditions with a blood test.

Freezing eggs starts with taking medications to encourage your ovaries to produce more eggs. Once this is complete, the eggs are collected in a minor surgical procedure under sedation. It’s mostly very safe, but there are some risks involved (heads up - this link uses gendered language).

Freezing sperm usually involves masturbating or using vibratory stimulation to collect a sample, which is then frozen and stored. If that’s not something you’re comfortable with, there are other options, like surgical sperm extraction, though these methods are more invasive and involve a minor surgical procedure.

You can now store eggs and sperm for up to 55 years (it was previously only 10 years for most people), though you’ll have to renew your consent every 10 years in order for the storage facility to lawfully continue storing them.

Where can I go for preservation?

You may be able to access fertility preservation under the NHS, but this is heavily dependent on where you live and what funding options are available locally to you. NHS funding decisions are made independently between England, Scotland, Wales and Northern Ireland, and in England, the decision is broken down further between different local Integrated Care Boards (ICBs).

Unfortunately, there is also no official guidance on NHS fertility preservation funding for transgender people, which means decisions on who gets access to this kind of care can vary, since there’s no clear direction for doctors or commissioning groups to follow.

If you want to pursue preservation under the NHS, your GP is the best person to advise you, as they should have information on funding specific to your area. Fertility Network UK also has lots of useful guidance on their website.

If you are able to financially, there is also the option of paying privately for preservation, as offered by services such as Care Fertility. The Human Fertilitisation and Embryology Authority (HFEA) has a tool on their website that can help you choose a private clinic that’s right for you.

Where can I find out more information?

The HFEA has a great resource that breaks down key information about fertility preservation for transgender and non-binary people which I recommend reading.

If you are thinking of starting gender-affirming hormone treatment with Eden New Life, you can read more about the expected effects on fertility via the Patient Information Sheets on testosterone and oestrogen available in our FAQs. Our specialists will also talk you through these effects and answer any questions you may have as part of your initial sessions prior to starting any hormones.

If you have already started gender-affirming hormone treatment and want advice on your fertility options, our specialists will be able to help in your regular review sessions.