Sperm Cryopreservation During Transition

Sperm cryopreservation is the freezing of sperm cells for future use in reproduction. In trans women, it is discussed before starting feminising hormone therapy or undergoing an orchiectomy.

What sperm cryopreservation involves

Sperm cryopreservation is the freezing and storage of sperm cells for future use. For people transitioning from male to female at birth, this fertility option is offered before starting feminising hormone therapy or undergoing an orchiectomy, because both interventions substantially and potentially permanently reduce fertility.

Why it should be done beforehand

Oestrogen suppresses spermatogenesis within weeks to months. In some patients, sperm production returns after stopping hormones; in others, it does not — and this is difficult to predict. An orchiectomy permanently eliminates sperm production. Anyone who may wish to father biological children in the future should therefore have sperm frozen before starting hormones or undergoing an orchiectomy.

Procedure

Sperm is produced through masturbation, sometimes via medical extraction if production has already been suppressed (TESE — testicular sperm extraction). Processing and quality control take place in a fertility laboratory. The sperm is frozen in liquid nitrogen at -196°C. Storage is essentially indefinite, although practical limits may apply through contracts and reimbursement arrangements.

Reimbursement in the Netherlands

For transgender people, cryopreservation has largely been reimbursed through the basic health insurance scheme since the 2010s, provided there is a fertility-related medical indication before gender-affirming treatment. Long-term storage costs may be charged separately. Policies may vary slightly between health insurers, so the specific coverage should be checked in advance.

For minors

This is a complex subject. Cryopreservation requires ejaculation after sexual maturation. For boys who start puberty blockers before reaching full sexual maturity, conventional cryopreservation is not possible. Experimental techniques — freezing testicular tissue for future reproductive technologies — are under development but are not routinely available. A twelve-year-old taking puberty blockers therefore loses the standard fertility-preservation option that he could still have used at fifteen. This contradiction is explored in more detail on puberteitsremmers.nl.

Not discussed as part of informed consent

There are documented cases — both internationally and in the Netherlands — in which patients later realised that fertility could have been preserved but that the subject had not been discussed, or had only been discussed in jargon. This directly concerns informed consent for gender care: without an explicit discussion of fertility, consent to suppressive hormones or an orchiectomy is not fully informed.

Future use

Frozen sperm can be used for IUI, IVF or ICSI. The pregnancy is carried by a partner, surrogate or, in countries where this is permitted, another gestational carrier. For trans women who later detransition, cryopreserved sperm remains an option for biological parenthood — whereas without cryopreservation, that option is lost.

What this means for the healthcare model

A serious healthcare system documents for each patient whether a fertility discussion took place before suppressive interventions. The reality in Dutch gender clinics is that this discussion is not conducted consistently — particularly with minors, for whom the issue is even more complicated, both medically (the technology) and ethically (a child’s capacity to understand the loss of potential future children).

Why before hormone therapy

Oestrogen therapy and anti-androgens suppress sperm production. Recovery after stopping treatment is incomplete and variable; an orchiectomy makes the loss permanent. International guidelines (Endocrine Society 2017, WPATH SOC-8 2022) therefore recommend discussing fertility preservation in good time — preferably before starting hormone treatment.

Procedure

The sperm is provided, usually through masturbation, at a fertility clinic, assessed for quality and frozen in liquid nitrogen. It can be stored for many years. If desired, it can later be used for IUI (intrauterine insemination) or IVF/ICSI with a partner or surrogate.

Reimbursement in the Netherlands

Fertility preservation for medical indications — including gender dysphoria — is reimbursed in the Netherlands through the basic health insurance scheme for freezing and, in principle, storage; conditions and storage periods vary between health insurers. For trans men, the equivalent procedure is egg freezing. The broader effects of hormones and surgery are discussed under fertility and transition.