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To preserve your fertility, you need to freeze your eggs or sperm. A trans woman can use banked sperm with an IUI conception method if she is in a relationship with a woman, or she can use an egg donor or gestational carrier if she is single or in a relationship with a man. A trans man who has frozen eggs can use a donor or partner sperm if they are in a relationship with a man, or if they are with a woman, they can use reciprocal IVF where the woman is inseminated with an embryo from donor sperm and the frozen eggs.

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In most cases, people regain fertility once they stop taking the hormones. However, there is some evidence that the longer a person takes estrogen hormone therapy, the less likely they are to have fertile sperm.

While tucking gives a more desirable presentation for many trans women, it can be damaging to spermatogenesis, the process of sperm production in the testicles. Testicles hang away from the body in the scrotum because sperm production requires a temperature approximately 5.5ºF lower than body temperature. Tucking or wearing tight undergarments increases the heat in the scrotum by up to 5ºF, impairing sperm production. This may be why trans women are more likely to have have poor sperm quality compared to cis men, even before they begin hormone treatment.

The correlation between tucking and low motile sperm count has been directly demonstrated. In fact, the act of tucking has been investigated as a potential contraceptive practice for cis men in several studies. In one study, researchers found that those who practiced tucking had very low motile sperm counts and a 0% pregnancy rate. In another, sperm production decreased by 97% after 2 months of daily tucking.

The good news is that sperm impairment caused by tucking appears to be entirely reversible within several months of pausing the practice. Still, this may be an important consideration for trans women who are considering sperm freezing for potential use later.

Testosterone is essential to the production of sperm. It plays a role in initiating several key processes in spermatogenesis, including the division and maturation of sperm cells. The goal of hormone therapy for transgender women is to decrease testosterone and increase estrogen levels to create a more typically feminine appearance. Estrogen therapy helps decrease testosterone levels in the body. Many trans women also use anti-androgens to further decrease their testosterone to typical female levels (around 70 ng/ml).

Testosterone levels under 264 ng/ml are associated with poorer semen parameters. And, as we would expect, use of estrogen and androgen-blockers is associated in research with poor sperm quality and lower sperm count. A 2017 review looked at nearly 40 years of research on the impact of cross-sex hormones on the sperm quality and testicular function of trans women. The review found that, in the majority of cases, estrogen and/or anti-androgen treatment caused reduced or halted spermatogenesis, as well as physical changes to the testicles.

The effect seems to be dose-dependent. In one study, a low-dose estrogen therapy had no impact on sperm concentration or motility, while a higher-dose regimen resulted in reduced sperm motility after just a few days and reduced sperm concentration after 2 weeks. Fertility preservation, including proactive sperm freezing, can help mitigate this.

Estrogen and anti-androgen medications may significantly impair sperm production. Freezing sperm prior to beginning medical transition will typically offer the best results. Trans women and girls can consider sperm freezing options as soon as they hit puberty and are able to produce a semen sample.

If the semen analysis determines you are still producing some healthy sperm, you can attempt to conceive with your partner naturally (via sexual intercourse). Alternatively, you could do an IUI if you want to increase the chances of pregnancy or are not comfortable with penis-in-vagina sex. Sperm freezing is also an option, ensuring you can create a pregnancy later.

Certain types of feminizing surgery may limit or end fertility. If you want to have biological children and you're having surgery that involves your reproductive organs, talk to your health care provider before surgery. You may be able to freeze sperm with a technique called sperm cryopreservation.

Orchiectomy is a surgery to remove the testicles. Because testicles produce sperm and the hormone testosterone, an orchiectomy might eliminate the need to use testosterone blockers. It also may lower the amount of estrogen needed to achieve and maintain the appearance you want.

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