Trans people who undergo long-term hormonal treatment and/or surgical procedures to remove the gonads are no longer fertile. However, there are options for transgender people to have children in other ways, such as adoption or via fertility treatments in some cases. For example, transgender people can also freeze their own gametes (sperm, egg cells) before they start a medical transition, if desired. It is important to consider the issue of fertility before the start of hormonal treatment and to discuss these options with your trans client. In many cases, when no gonadectomy has been performed, fertility may also be gained back if hormone treatment is stopped or paused.
In Malta, trans persons and non-binary persons can preserve their gametes before gender-assigning medical and/or surgical treatments, at the Assisted Reproductive Technology (ART) Clinic at Mater Dei Hospital through the National Healthcare System.
Fertility preservation with trans men and non-binary people assigned female at birth
Trans men and non-binary people assigned female at birth can freeze ova, but this requires hormonal stimulation with oestrogens. An ovarian puncture is preferentially performed from the age of 18 and preferably takes place before the start of hormone treatment. If taking place before starting hormones, three weeks stimulation with oestrogens is needed. If hormone treatment has already started, it must be temporarily stopped for about 3 to 6 months followed by the three week oestrogen stimulation. During this procedure, oestrogens are administered, allowing multiple oocytes to mature. The follow-up of this ovarian stimulation is done via vaginal echo monitoring. For many trans men and non-binary people assigned female at birth, this is psychologically and emotionally difficult, so it is prudent to ensure that the trans person has access to mental health support if they need it during the process.
If a trans man or non-binary person assigned female at birth wants to use his/their own gametes with certainty and also wishes to undergo hormone therapy and gonadectomy, then the only method currently available is the freezing of ova.
Fertility preservation in trans women and non-binary people assigned male at birth
For trans women and non-binary people assigned male at birth, sperm cells can be frozen before the start of hormone therapy, if applicable, which can then possibly be used later in fertility treatment. However, testosterone blockers have a negative effect on sperm quality and thus fertility, so it is recommended to freeze sperm prior to initiating testosterone blockers. Estrogen treatment without antiandrogens has a negative (but reversible) effect on the sperm characterisitcs.
There is no minimum age for sperm freezing, but trans girls who have already started puberty blockers in their early puberty may not have the ability to freeze sperm because they have not reached the puberty phase in which sperm cells are developed. The stage in sex development when sperm is produced must first have been reached. A possible response to this is the freezing of testicular tissue. This technique may therefore be desirable for prepubescent trans girls. However, the use of this testicular tissue is yet still very underdeveloped.
Many trans persons are not comfortable with masturbating to produce sperm cells to freeze. In that case, extraction of testicular tissue may be best, because the removal of testicular tissue is a surgical procedure and can be combined with genital surgery (if the trans person is 18 years old). The use of this tissue to fulfil the desire to have children lies in transplanting the testicular tissue. However, this is not possible following gonadectomy, since there are no longer any testes present. It is currently not possible to obtain sperm cells from this tissue via an in vitro maturation (i.e. completely done in a laboratory).
It is much simpler to freeze sperm cells when possible, because the frozen sperm cells offer the only absolute certainty that they can be used in fertility treatment. The use of the frozen testicular tissue is currently very experimental, and therefore offers no guarantee whatsoever of use in future fertility treatment. So, if a trans woman or non-binary person assigned male at birth wants to use her/their own gametes with certainty and also wishes to undergo hormone therapy and gonadectomy, then the only method at this moment is freezing sperm.
Fertility treatment
When considering fertility treatment, it is important to consider the bodies of the parents to decide on a course of treatment. Many types of couples exist who may want to have genetically related children, and appropriate treatment methods depend on whether one or more of the partners have ovaries and a uterus, or testes.
When both partners have functioning uteri and ovaries (e.g. a trans man and a cis woman, or two trans men), the frozen egg cells of one partner can be used for in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) with a sperm from an anonymous or known sperm donor. A trans man whose cisgender female partner gives birth to a child conceived through donor insemination can officially recognize the child as his and is thus noted as a father on the birth certificate (just like an infertile cisgenderman whose wife gives birth through donor insemination).
If the trans man or non-binary person assigned female at birth still has a uterus and ovaries and has a cisgender male partner, then the sperm from the partner can be used to fertilise the (frozen) egg cells or through vaginal-penile insemination. As a result, any resulting child is genetically related to both parents. If the trans man or non-binary person assigned female at birth no longer has an uterus, surrogacy is required. Surrogacy is currently a criminal offence in Malta although it is possible to access such services in a few countries overseas.
A trans woman and a trans man who have not yet undergone gender-confirming treatment can, in principle, conceive a child together as well.
The possibility for trans women to be pregnant themselves and to give birth to a child is currently non-existent. However, if the partner is a cisgender female, the frozen sperm cell of the trans woman can be used for insemination. If the quality of the frozen sperm is good, the partner can be directly inseminated, and otherwise techniques such as in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) can be used to fertilize the egg. Because of this any resulting child is genetically related to both parents. If the partner is a cisgender male, an egg donor and a surrogate mother will be required. Surrogacy is currently a criminal offence in Malta although it is possible to access such services in a few countries overseas.