Fertility and Transition

Q: When should I consider cryopreservation?

Before starting hormones or puberty blockers. After that, the quality of the sex cells rapidly declines; when blockers are followed by hormones, cryopreservation is practically no longer possible. The gonads have never developed. Guidelines stipulate that fertility must be discussed before treatment.

Q: Is cryopreservation covered by health insurance?

When medically indicated, including in cases of gender dysphoria, freezing is covered in the Netherlands by the basic health insurance and, in principle, storage is covered as well. The conditions and storage periods vary between health insurers. Ask about them in advance. Do this before starting hormones, because the quality of the sex cells declines afterwards.

Q: Can a trans man become pregnant?

Yes, if the uterus and ovaries are intact and the menstrual cycle returns after stopping testosterone. Medical supervision is essential; pregnancy while taking testosterone is medically risky for the foetus. Documented pregnancies are known. It requires intensive medical and psychosocial support. After long-term testosterone use, recovery of the menstrual cycle is uncertain.

Q: Is sperm cryopreservation possible after long-term oestrogen use?

Sometimes, after temporarily stopping treatment, but the results are uncertain and sperm quality may remain permanently reduced. Oestrogen therapy suppresses sperm production, and with long-term use this may be irreversible. It is therefore advisable to consider cryopreservation before starting hormones. For biological parenthood, trans women depend on previously frozen sperm.

Q: What if I have had puberty blockers followed by hormones?

Biological parenthood is then probably no longer possible. This is one of the compelling reasons why countries such as Sweden, Finland and the UK have restricted this pathway for minors. Cryopreservation is practically impossible with this pathway because the gonads have never developed.

IVF laboratory with workbenches and microscopes — Photo: Dr.jayesh amin, CC BY-SA 3.0, via Wikimedia Commons

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

Impact of hormone therapy on fertility

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

Impact of puberty blockers

This is an underreported but crucial point. Puberty blockers followed directly by sex hormones — the standard pathway in the Dutch Protocol — make the cryopreservation of sex cells practically impossible because the gonads have never developed:

For girls: no mature eggs are available for cryopreservation.
For boys: no mature sperm cells; 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) identifies fertility preservation as one of the central shortcomings in current gender care for young people: at the time of decision-making, minors are unable to fully comprehend the loss of future parenthood.

Impact of surgery

Orchiectomy, hysterectomy and oophorectomy constitute permanent sterilisation. In vaginoplasty using penile inversion, the testicular tissue is removed. In phalloplasty, the uterus may be preserved or removed. What permanent infertility after surgery means is described by transitieschade.nl.

Cryopreservation of sex cells

Trans women: sperm banking before starting oestrogen or undergoing orchiectomy. Simple, non-invasive and widely available. With short-term hormone use, viable sperm may sometimes still be collected after temporarily stopping treatment, but this is uncertain.
Trans men: oocyte cryopreservation or embryo cryopreservation. This requires hormonal stimulation and a vaginal retrieval procedure — which can be difficult for some because of the feminising hormones and the nature of the procedure.
Minors: experimental options (ovarian or testicular tissue) are still at the research stage and offer no guarantees.

Pregnancy after or during transition

Pregnancy is possible for trans men who retain their uterus and ovaries, after stopping testosterone and recovering their menstrual cycle. Documented pregnancies are known. It requires intensive medical and psychosocial support. For biological parenthood, trans women depend on previously frozen sperm in combination with surrogacy or, in a research setting, uterine transplantation.

Counselling and informed consent

WPATH and other guidelines stipulate that fertility must be discussed before treatment. In practice, this is not done systematically enough, particularly with adolescents and in informed-consent models that prescribe hormones quickly. For minors, the capacity to comprehend an irreversible decision about future parenthood is inherently limited. Critics, including the Cass Review, emphasise that it is unethical to accept medical sterilisation as a by-product without the patient being able to assess its true significance.

When should I consider cryopreservation?

Is cryopreservation covered by health insurance?

Can a trans man become pregnant?

Is sperm cryopreservation possible after long-term oestrogen use?

What if I have had puberty blockers followed by hormones?