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Fertility and transition

Medical gender transition impairs fertility — sometimes permanently. For some, that is an accepted price; for others, it is a loss that only becomes truly visible later in life. Adequate information beforehand is therefore not an optional extra, but a medical and ethical precondition. In practice that information falls short, particularly in young people.

Effect of hormone therapy on fertility

• Oestrogen therapy suppresses sperm production. With long-term use this can be irreversible — sperm quality often remains reduced even after stopping.
• Testosterone therapy suppresses ovulation and menstruation. With short-term use recovery is likely; with long-term use uncertain. Pregnancy during testosterone is possible but medically risky for the foetus.

Effect of puberty blockers

This is an under-discussed but crucial point. Puberty blockers that are immediately followed by sex hormones — the standard route in the Dutch Protocol — make cryopreservation of gametes practically impossible because the gonads have never developed:

• In girls: no mature eggs available for cryopreservation.
• In boys: no mature sperm; only experimental testicular tissue biopsy is an (unproven) option.

Permanent infertility is therefore a likely outcome of the full Dutch Protocol pathway. The Cass Review (2024) names fertility preservation as one of the central shortcomings in current gender care for young people: minors cannot possibly fully grasp the loss of future parenthood at the moment of decision-making.

Effect of surgery

Orchidectomy, hysterectomy and oophorectomy are permanent sterilisation. With vaginoplasty via penile inversion, the testicular tissue is removed. With phalloplasty the uterus can be retained or removed.

Cryopreservation of gametes

• Trans women: sperm banking before starting oestrogen or before orchidectomy. Simple, non-invasive, widely available. With short-term hormone use, viable sperm can sometimes still be retrieved after temporary discontinuation, but this is uncertain.
• Trans men: oocyte cryopreservation or embryo cryopreservation. Requires hormonal stimulation and a vaginal puncture — experientially burdensome for some because of the feminising hormones and the nature of the procedure.
• Minors: experimental options (ovarian or testicular tissue) are research-stage and offer no guarantees.

Pregnancy after or during transition

Pregnancy in trans men retaining uterus and ovaries is possible, after stopping testosterone and the cycle resuming. Documented pregnancies are known. It requires intensive medical and psychosocial support. Trans women are reliant on previously frozen sperm in combination with surrogacy or (in a research setting) uterus transplantation for biological parenthood.

Counselling and informed consent

WPATH and other guidelines prescribe that fertility be discussed before treatment. In practice this happens insufficiently systematically, particularly in adolescents and in informed-consent models that prescribe hormones quickly. In minors the capacity to weigh an irreversible decision about future parenthood is by definition limited. Critics, including the Cass Review, stress that it is unethical to accept medical sterilisation as a by-product without the patient being able to grasp its actual weight.