Fertility Considerations for Gender-Affirming Bottom Surgery Patients

Despite the common misconception that transgender people do not wish to have biological children, about 19% of transgender U.S. adults are parents. While most genital or “bottom” procedures alter or eliminate the ability to conceive children, fertility is possible for transgender and nonbinary individuals. So, it is crucial that someone considering gender-affirming bottom surgery discuss their desire or potential desire to have biological children with a surgeon prior to scheduling their surgery.


Factors that affect fertility

Some non-surgical gender-affirming care treatments, such as puberty suppression, testosterone therapy, estrogen therapy or hormone blockers, may also impact fertility. If you are considering having biological children and have questions about the effect of these treatments on your fertility, please contact the healthcare provider who prescribed these medications for you.


Other factors that can impact fertility include age, weight, diet and nutrition, alcohol or drug use, sexually transmitted infections and other reproductive issues.


Your partner’s general health and medications can also impact fertility and may require separate evaluation. Communicating any fertility concerns in advance of your surgery is important. Fertility evaluation and treatment can take months to complete, most bottom surgery operations can permanently impact your ability to conceive children, and some patients prefer to postpone surgery until they are no longer interested in fertility.


Fertility options for patients assigned female at birth

Options for fertility preservation include egg or embryo banking, as long as you have not already undergone an oophorectomy (removal of the ovaries). A reproductive endocrinologist (a gynecologist specializing in fertility) typically performs this procedure. It is typically preceded by hormonal stimulation. Achieving a viable pregnancy using egg or embryo banking can be costly, require repeat treatments and nay not be covered by insurance.


For those who wish to take an alternative path, uterus preservation is an option that virtually all bottom surgery procedures for transgender men – such as phalloplasty and metoidioplasty – can include. Preserving the uterus also conserves the vagina, allowing cells and fluid produced by the uterus and cervix to exit the body. It is important to note that urethral lengthening performed during vagina-preserving phalloplasties and metoidioplasties can increase the risk of pregnancy complications.


Fertility options for patients assigned male at birth

Transgender women who have not undergone orchiectomy (removal of the testicles) may see a local urologist or reproductive specialist for sperm banking. Gender-affirming hormonal treatments can dramatically reduce sperm count, so if you are undergoing this type of treatment, you may need to stop hormones for a while to increase your sperm count. Please note that it can take up to three months to improve your ability to produce new sperm after pausing hormone treatments.


While Align’s surgeons don’t directly perform fertility counseling or fertility treatment, what we can do is discuss options, planning and timing to find the right surgical treatment to suit your fertility wishes. If you have questions about fertility and gender-affirming bottom surgery, please don’t hesitate to reach out to us. We’re here to help!




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