LGBTQ+ Fertility Preservation: What Trans and Nonbinary Patients Should Know

Clinically reviewed by Susan Nasab, MD

If you’re trans or nonbinary and want to build a family in the future, you have options. Having a fertility consultation before beginning to receive gender-affirming care will provide you with the most options, but even if you’ve already begun, there may still be a way to preserve fertility. In this article, we’ll cover what you need to know about fertility preservation while taking steps to live life as your truest and fullest self.

What to Know About Fertility Preservation for Trans and Nonbinary Patients

For many trans and nonbinary individuals, gender-affirming care is life-saving, essential healthcare. Certain treatments can, however, impact your options for building a family one day if that’s your goal. That’s why many trans and nonbinary people choose to freeze eggs, sperm, or embryos before receiving gender-affirming care as part of a process called fertility preservation.

Fertility preservation might not be right for everyone considering or receiving gender-affirming care, but it’s helpful to understand the options available as early in the journey as possible. If having children who are biologically related to you may be something you want in the future, seeing a fertility specialist before you begin gender-affirming care can help you have the best chances of conception later on.

“For individuals born with ovaries, we know they are born with a finite number of eggs, and that ovarian reserve naturally declines over time,” explains Dr. Susan Nasab, a Reproductive Endocrinologist and Infertility Specialist with a long career of supporting trans and nonbinary patients. “For individuals born with testes, sperm production occurs continuously, but hormone therapy can significantly affect sperm quality and quantity. In some cases, fertility may recover after stopping treatment, but in others, especially after certain surgeries, recovery may be difficult or even impossible.”

“Even if family building feels far away, a consultation with a fertility specialist can provide valuable information and help patients understand what options may be available both now and in the future,” explains Dr. Nasab. 

Why This Matters

Knowing if and when fertility preservation may be an option can help you think about and plan for your future. That information can be useful regardless of whether or not you know what you want long-term. What you do with that information next is completely up to you.

“Life circumstances, relationships, and personal goals can change over time,” says Dr. Nasab. “If a patient decides not to pursue fertility preservation, that is absolutely their choice. My goal is to ensure that decision is made with complete information, education, and informed consent.”

The Fertility Preservation and Treatment Process

The process of fertility preservation and treatment will be different for each individual, but there are several options available:

Fertility Preservation

For transmasculine individuals, fertility preservation can include:

• Egg extraction and freezing
• Embryo freezing (fertilizing eggs using a partner or donor’s sperm before freezing) and banking (storing multiple embryos for future pregnancies)

For transfeminine individuals, fertility preservation can include:

• Sperm freezing
• Embryo freezing (fertilizing a partner or donor’s eggs with your sperm before freezing) and banking (storing multiple embryos for future pregnancies)
• Surgical sperm extraction in selected cases

Fertility Treatment

For Transmasculine Individuals

Your frozen eggs or embryos can be used in the future through in vitro fertilization (IVF). You may choose to carry the pregnancy yourself if you have a uterus and wish to do so, or your embryos can be transferred to your partner's uterus or to a gestational carrier (surrogate).

For Transfeminine Individuals

Your frozen sperm can be used in the future for intrauterine insemination (IUI) or in vitro fertilization (IVF) with your partner's eggs, donor eggs, or embryos you have previously created. The resulting pregnancy can be carried by your partner if they have a uterus, or by a gestational carrier (surrogate). If embryos have already been created and your partner has a uterus, they may also choose to carry the pregnancy through reciprocal IVF or standard embryo transfer, depending on your family-building goals.

What Affects Your Options or Outcomes

Your unique transition journey will impact your options and potential outcomes. “Every patient's journey is different,” says Dr. Nasab. “The stage of transition, prior treatments, and individual biology all matter.” This is why having an individualized evaluation to understand your options is so important.

If you are going to receive gender-affirming care

The best time to have a fertility preservation consultation is before starting gender-affirming hormone therapy or other types of gender-affirming care. Regardless of what you decide, you can move forward fully informed about current or future fertility.

If you are receiving gender-affirming hormone therapy

“One of the biggest misconceptions I encounter is the belief that once someone has started hormone therapy, fertility preservation is no longer possible. In many cases, that is simply not true,” explains Dr. Nasab. However, stopping treatment can be very difficult mentally, emotionally, and physically, which is why Dr. Nasab and other experts advise fertility preservation before beginning hormone therapy.

Masculinizing Hormone therapy (Testosterone)

If you are taking testosterone, you may need to temporarily pause treatment before ovarian stimulation. While older recommendations advised stopping testosterone for 3–6 months, current evidence suggests that many patients can successfully undergo egg retrieval after a much shorter interruption (often 2–6 weeks), and some centers are studying stimulation without stopping testosterone. Your fertility specialist will individualize the timing based on your hormone levels, ultrasound findings, and treatment goals.

“For individuals born with ovaries, as long as the ovaries have not been surgically removed, there may still be opportunities to pursue egg retrieval, embryo creation, and fertility preservation,” says Dr. Nasab.

Feminizing Hormone Therapy (Estrogen)

Estrogen and anti-androgen therapy can significantly reduce or even temporarily stop sperm production. In many individuals, sperm production recovers after discontinuing hormone therapy, although the time to recovery varies widely—from a few months to a year or longer. Your fertility specialist may recommend temporarily stopping hormone therapy and monitoring semen analyses over time. If sperm do not return in the ejaculate, medical therapy or surgical sperm retrieval may be appropriate.

While a temporary pause in estrogen therapy is often recommended before sperm cryopreservation, there is no universally required duration. Many providers begin reassessing sperm production after approximately 2–3 months, although recovery may occur sooner or require additional time depending on the individual.

For some, following the typical protocol for sperm collection—masturbating, maintaining an erection, and then ejaculating into a sample cup—can be distressing. Surgical extraction may be more comfortable. Your provider can help you figure out the best path forward for you.

If you have had gender-affirming surgery

Masculinizing Surgery

If you have had your uterus and/or ovaries surgically removed through a hysterectomy or oophorectomy, you will no longer be able to use your eggs to conceive or carry a pregnancy. However, if you’ve had other forms of gender-affirming surgery, you may still be able to access the tissue and cells necessary for biological reproduction.

“Some patients may not wish to carry a pregnancy themselves, or they may have undergone procedures involving the uterus, but that does not necessarily eliminate the possibility of having a biologically related child through IVF and embryo banking,” explains Dr. Nasab.

Feminizing Surgery

If you have had your testes removed through an orchiectomy, you will no longer be able to use your sperm to have a biological child.

There are many paths to building families. Patients who are unable to extract eggs or sperm, as well as those who don’t want to or can’t carry a pregnancy, still have options. You can use donor eggs or sperm, ask a partner or surrogate to carry the pregnancy, or consider adoption.

FAQs

Can insurance cover fertility preservation for trans and nonbinary patients?

Sometimes. Only six states and Washington, DC require private insurance providers to cover fertility-related services for LGBTQ+ individuals and specifically include at least some fertility preservation: 

• California
• Colorado
• Illinois
• Maine
• New Jersey
• New York
• Washington, DC

Only four states require Medicaid to cover some fertility preservation for some people: 

• Illinois
• Maryland
• Montana
• Utah

Reach out to your insurance provider if you aren’t sure what your plan will cover.

Can insurance cover fertility treatment for trans and nonbinary patients?

Sometimes. Only six states and Washington, DC require private insurance providers to cover fertility-related services for LGBTQ+ individuals: 

• California
• Colorado
• Illinois
• Maine
• New Jersey
• New York
• Washington, DC

Reach out to your insurance provider if you aren’t sure what your plan will cover.

What are my options for growing a family if I don’t do fertility preservation before receiving gender-affirming care?

We understand that for many people, having biological children is an important goal. For those who are open to alternative paths to parenthood, there are several options that don’t require using your own eggs, sperm, or ovaries:

• You can use donor eggs or sperm.
• You can ask a partner or surrogate to carry a pregnancy.
• You can consider adoption.

We’re here to help you figure out the best way to grow your family.

Care at Celenova Fertility

Celenova Fertility is led by Dr. Nasab, a fertility specialist with decades of experience supporting trans and nonbinary patients, as well as patients in cancer treatment, through fertility preservation. We are committed to making these services as affordable as possible, regardless of insurance coverage or fertility benefits. 

In California, most insurance plans are required to cover fertility preservation and treatment for LGBTQ+ individuals. However, Medi-Cal (Medicaid) plans, small group employers (fewer than 100 employees), religious organizations, and self-funded employers are exempt from this requirement.

If your plan does not cover fertility preservation, our financial counselors can guide you through available payment options, including fertility grants, scholarships, and loans.

Next Steps for Patients at Celenova Fertility

Regardless of where you are in your journey, we welcome the opportunity to meet with you to discuss your options for fertility preservation and create a plan that works for you.

Schedule your consultation today at Celenova Fertility.

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