Second report of trans man undergoing successful fertility preservation without stopping testosterone – this time producing a viable embryo and live birth

Over the past few years, several studies have explored how the use of testosterone as part of transmasculine transition can affect the potential for fertility in those who still have ovaries. These findings have represented a steady progression toward overturning much of the conventional wisdom on fertility in the context of HRT. Although it has long been known that testosterone is not an effective contraceptive for trans men and transmasculine people who still have a uterus and ovaries, and both intended and unintended pregnancies have been reported while on testosterone (Light et al., 2014), pausing HRT to undergo fertility preservation procedures such as oocyte (egg) retrieval has been a widespread practice. This pause can lead to undesired effects, such as worsening gender dysphoria and the resumption of physical feminization (Armuand et al., 2017).

Along these lines, researchers have examined how long of a pause in testosterone is needed for successful retrieval of viable eggs, and the findings have been promising: Among a group of trans men who had been taking testosterone for an average of 3.7 years and paused HRT for an average of 4 months, all were able to retrieve normal numbers of oocytes that later led to successful pregnancies. In another case report, one trans man paused testosterone for only 24 days and underwent successful oocyte retrieval and preservation during this time. And this year, clinicians reported that a trans man who had been on HRT for 18 months had successful fertility preservation of 22 oocytes while not pausing testosterone at all.

This previous report was the first known instance of fertility preservation without any interruption of masculinizing HRT. A second case now provides replication and confirmation that oocyte retrieval can be successful while remaining on long-term testosterone treatment.

Greenwald et al. (2021) report that a 33-year-old trans man who had been taking testosterone for 10 years elected to undergo fertility preservation without pausing HRT. After a 14-day course of ovarian stimulation, 16 mature oocytes were retrieved. Although no pregnancy outcomes were available for the previous case (Gale et al., 2021), the trans man in the present report had 13 eggs fertilized with donor sperm, with five becoming blastocysts. Of those five, four had aneuploidy, an abnormal number of chromosomes that is unlikely to produce a viable pregnancy. The remaining viable embryo was transferred to his cis woman partner, resulting in an uncomplicated pregnancy and full-term birth of a healthy and developmentally normal child. This demonstrates for the first time that ovarian stimulation during continued testosterone treatment can permit not only successful egg retrieval, but also normal pregnancy and birth following the fertilization of these eggs.

The authors observe that while egg retrieval from 33-year-old cis women typically results in aneuploid embryos at a rate of 31%, in this case, 80% of this trans man’s embryos were aneuploid. Crucially, this represents a sample size of one, as the previous case report did not feature fertilization of the retrieved eggs. They note a “need for further research on the topic” to clarify any potential effect of ongoing testosterone treatment on the occurrence of aneuploidy in embryos resulting from these oocytes. This case confirms that trans men can potentially produce mature oocytes and viable pregnancies while choosing not to pause their testosterone, and as more trans men and transmasculine people choose this option, further information will become available on any special considerations for this protocol. ■