Being Trans and Grappling With Your Fertility

Banking sperm during a pandemic can be a daunting task. Samples must be returned to a clinic within one hour of being produced at home, instead of in a fertility clinic, because of strict social distancing rules. I live in Atlanta, Georgia, notorious for its traffic. Even during a pandemic, a trip to the doctor’s office can sometimes mean sitting in endless traffic on an interstate highway. I’ve made this trip three times already this year, and plan to do it at least two more times before the year is up. Each trip costs around $400 out of pocket even with a wonderful insurance plan, and produces around two to three vials of sperm per trip. I am doing all this because I want to have a child with my partner in the near future, and I am a transgender woman. Having one’s own biological child is not always as easy as the movies make it out to be. Due to factors like timing and underlying health conditions, fertility treatments are becoming more and more common—a third of Americans have either used them or know someone who has. For people of any gender, cost is often a major consideration; procedures like IVF are rarely covered under most health insurance plans, and some treatments can carry a price tag of tens of thousands of dollars. But when you’re transgender and navigating this process in a world that centers cishet people, there are all kinds of other considerations that go beyond the dollar amount. First, there are the logistics of conception itself. Once I start hormone replacement therapy (HRT), my sperm will no longer be viable for achieving natural conception. We are saving up to be able to afford intrauterine insemination, which would allow my sperm to be placed in my partner’s uterus, potentially conceiving a child. If multiple rounds of that do not work, we are prepared to pay for in vitro fertilization in hopes of getting viable embryos to one day conceive. “Natural” conception can be an option for trans-identifying individuals; HRT is only one potential treatment to alleviate gender dysphoria, and not every trans person decides to take them. Yet, for those who view it as a must for their transition, becoming a biological parent means taking a variety of steps to preserving their reproductive material (either sperm or eggs).

Stopping hormones comes with some psychological risks for trans patients, and "a feeling of loss."

Nina Resetkova, a reproductive endocrinologist at Boston IVF, says that trans patients need to consider the question: How important is having a biological child to you before medically transitioning, and how important is it to your partner? If the answer is "important" or "very important," then patients can consider a variety of options to fulfill that goal. For both transmasculine and transfeminine patients, banking reproductive material, be it eggs or sperm, is an option before starting HRT. Even after starting hormones, studies have shown that both transmasculine and transfeminine patients are able to produce viable eggs and sperm when stopping hormones for a few months. Still, stopping hormones comes with some psychological risks for trans patients. For transmasculine patients, they may begin getting their periods again, which could be a source of anxiety and distress. Transfeminine patients will have to deal with lower sperm counts after going off testosterone blockers. Other physical changes as a result of gender-affirming hormones will subside, too. “A lot of the forward progress have made taking hormones for a long period of time, there is this feeling of loss of that progress that’s pushed to the side,” Resetkova says. Fortunately, that feeling of loss is usually not long term. Transmasculine patients may only need to be off hormones for one to four months in order to freeze viable eggs, and transfeminine patients may only need to be off hormones for three to six months to bank viable sperm, says Resetkova. “Generally speaking, we’re able to accomplish fertility treatment in a fairly short period of time.” Still, the price is a huge barrier for lots of people. The five-figure price tags for IVF are some of the most expensive treatment offerings, but egg freezing can also cost up to $10,000. Sperm banking is considerably cheaper, with each deposit costing only a few hundred dollars, but depending on whether a patient deposits sperm at a fertility clinic or through another provider, there could be additional yearly storage costs. All these considerations can weigh mightily on couples who are on the fence about having biological children while one partner is transitioning. Lauren and Sam Guilbeaux chronicled a part of their journey to enlarge their family on the Showtime series Couples Therapy where Sam tried, unsuccessfully, to conceive using IUI. The pair have a limited amount of Lauren’s sperm after the attempt, and the experience made them both rethink the process and their wants and needs for a family.

"I wish people would take a second to deconstruct the trans experience and realize all that we have to do."

“The process of trying to conceive for the first time, via IUI, was incredibly taxing on our relationship,” Lauren and Sam told me in a joint email. “We didn't conceive and that sent us back to the drawing board with a little more humility and understanding.” Realizing there was only so much sperm to work with was eye-opening for both partners. “The next time we try, we'll go through IVF. However, at nearly $30K and without help from insurance, it's not in the cards for us in the near future.” Lauren says that anyone who's planning to bank material during transitioning should keep all this in mind while doing research. “Just because you save doesn't mean you'll have an easy shot at having biological kids,” Lauren says. Lauren began the process of starting HRT in 2014, at a time when trans people were less visible in public spaces and information about fertility in general was less available. So she turned to the internet to find answers. For many trans people looking to cut down on costs, but still preserve material for future kids, online companies have become a lifeline. Services such as “Dadi” and “Xytex” allow trans patients to store material without having to face the anxiety of potentially seeing a non-trans-affirming doctor face-to-face. Robbi, a trans woman living in Spokane, Washington, says she delayed medically transitioning for multiple years because she wanted to bank sperm in hopes of one day having a biological child. After finding a company that allowed her to store reproductive material by sending samples through the mail, Robbi received devastating news: She was infertile. Despite the outcome of the process, she hopes her story allows others to see the many hurdles trans people face when seeking fertility treatment. “ they are just bewildered there is a cost associated with these things,” Robbi said. “It depends on what state you are in, and even in the best of states your odds aren’t always great. I wish people would take a second to deconstruct the trans experience and realize all that we have to do.” The fertility industry in the United States is growing rapidly as more parents-to-be tap into an estimated $6 billion industry. There are plenty of websites and podcasts that share all kinds of birth stories and have helped normalize fertility struggles. Part of this normalization needs to include trans people’s experiences, and the stressful foresight and preparation they often grapple with when planning for a biological child.