First report of trans man having successful fertility preservation without interrupting HRT

Successive studies have worked to pin down how testosterone used in masculinizing HRT can affect fertility in trans men and transmasculine people who still have a uterus and ovaries. Despite popular misconceptions, HRT as part of medical transition generally does not have a permanently sterilizing effect. Instead, reductions in fertility may be temporary or reversible – or even nonexistent. Trans men may seek to preserve their fertility prior to gonadectomy (surgery that includes removal of the ovaries) using ovarian stimulation and cryopreservation, in which oocytes are released, extracted, and frozen. Crucially, this can be performed even after starting masculinizing HRT.

Leung et al. (2019) found that trans men who had been on testosterone for years could still have eggs successfully retrieved after discontinuing testosterone for four months, and they were able to retrieve about the same number of eggs as cis women. The authors also raised the question of “whether ovarian stimulation can be done with any measure of success without the cessation of testosterone”. Cho et al. (2020) later reported the case of a trans man who stopped taking testosterone one week before ovarian stimulation, ultimately discontinuing testosterone for only 24 days, with successful retrieval of eggs.

Now, Gale et al. (2021) appear to have found the limit here: There may not be one. The patient in this case was 20 years old and had been taking testosterone for 18 months, and while the authors note that discontinuing testosterone for 1-3 months is typically recommended because of its “unknown impact” on ovarian stimulation outcomes, he opted to continue taking HRT throughout the process. After the ovarian stimulation protocol, he had 25 eggs retrieved and 22 successfully cryopreserved:

This case report demonstrates a proof of concept that undergoing a cycle of oocyte cryopreservation while continuing long-term testosterone therapy is possible. . . . Given the perceived potential negative impact of either delay of the start of testosterone therapy in order to pursue fertility preservation or the cessation of testosterone once already commenced prior to the start of ovarian stimulation, continuation of testosterone therapy throughout the fertility preservation process should be further explored.

As Cho et al. point out, the requirement to stop HRT for a period of weeks or months is a barrier to fertility preservation in trans men because of the distress this causes. Patients in the Leung study experienced the return of menses as well as female-typical estradiol levels, which can worsen gender dysphoria. As this is only a single case report, it does not show that trans men who continue taking testosterone will generally have ovarian stimulation results on par with those who temporarily discontinue it; this has yet to be examined in larger samples. However, if these results can be consistently obtained, the unpleasantness of pausing HRT may also turn out to be unnecessary. ■