Human Reproduction Vol.16, No.4 pp.

612614, 2001

DEBATEcontinued
Gender reassignment and assisted reproduction
Present and future reproductive options for
transsexual people
Paul De Sutter1
Infertility Centre, University Hospital Ghent, De Pintelaan 185,
B-9000 Gent, Belgium.
1To

whom correspondence should be addressed.

E-mail: paul.desutter@rug.ac.be

Transsexual people who want transition to their desired

gender have to undergo hormonal and surgical treatments, which lead to irreversible loss of their reproductive
potential. This paper argues that transsexual people should
be offered the same options as any person that risks losing
their germ cells because of treatment for a malignant
disease. Indeed, transsexual women (male-to-female
transsexual patients) may be given the option to store
spermatozoa before they start hormonal therapy, so that
their gametes may be used in future relationships. This
may be especially important for the many transsexual
women who identify as lesbians after their transition.
Conversely, transsexual men (female-to-male transsexual
patients) may be offered storage of oocytes or ovarian
tissue, possibly obtained at the time of their oophorectomy.
Current technology offers transsexual people the possibility
to obtain children who are genetically their own in their
future relationships and the option of gamete banking
should therefore be discussed before starting hormonal
and surgical reassignment treatment. This is particularly
important for transsexual people who are diagnosed and
treated at a young age.
Key words: gamete preservation/reproduction/sperm freezing/
transsexual/transgender

Introduction
Transsexualism (Benjamin, 1966) is the most extreme form of
gender dysphoria (Fisk, 1973), which means that an individual
has a feeling of belonging to the gender opposite to his or her
own gender, as determined by his or her primary and secondary
sexual characteristics. Although transsexualism has long been
thought of as a mental disorder, evidence clearly shows that
this is not the case (Haraldsen and Dahl, 2000). The diagnosis
transsexualism per se has been removed from the Diagnostic
and Statistical Manual of Mental Disorders (Fourth Edition)
(APA, 1994) and replaced by the more general term gender
612

identity disorder. Transsexualism is now generally recognized

to be a condition that needs to be treated by state-of-the-art
hormonal and surgical therapy to obtain reassignment to the
desired gender [see also the standards of care in (Levine et al.,
1998)]. Reassignment therapy normally only takes place after
psychiatric evaluation to rule out co-morbidity, and surgery is
moreover only performed after a successful real life test,
which means that the individual must have lived a specified
amount of time (usually one or two years) in the desired
gender role.
Until recently, transition to the desired gender and reproduction seemed to be mutually exclusive for transsexual people.
To many, loss of reproductive potential seems the price to
pay for transition. Even today, many medical expertseven
those involved in the care for transsexual and transgendered
peopleare still critical when discussing possible procreation
after gender reassignment. However, recent publications have
opened the ethical debate as to whether transsexual people
should be helped in their possible wish for children in
relationships occurring after transition (Brothers and Ford,
2000; Jones, 2000). The debate has only just started amongst
fertility experts and currently only deals with donor inseminations in female partners of transsexual men (female-to-male
transsexual patients). The question posed is whether transsexual
people can be good parents, without negative influence on
the gender and/or sexual orientation of the child-to-be, a
discussion that was held many years ago for homosexual
people (Hanscombe, 1983). As it was to homosexuals then,
this question may be considered to be an insult to transsexual
people, and we rather believe that the debate should be
broadened and discuss the possibilities of how to help fulfil
the wish for children by transsexual people, rather than whether
to help them or not. The overall wellbeing of transsexual people
after gender reassignment therapy has been well documented in
recent studies (Cohen-Kettenis and Gooren, 1999) and many
of these people have normal relationships with children from
their previous relationships or from their current partners.
More and more, people are diagnosed and treated for their
transsexuality at an early age, when they still do not have
any children nor possibly any wish for children. Recent
reproductive techniques, however, have made it possible to
preserve germ cells for future use, so that in theory transsexual
people may make use of their germ cells after transition. A
few years ago Lawrence et al. discussed the reproductive
needs of the transsexual patient (Lawrence et al., 1996),
taking Lawrences ideas further, the purpose of this paper is
to discuss what is already technically possible now, and what
may be possible tomorrow. Of course, we may expect that the
medical and ethical debate will continue before these new
techniques may be implemented routinely.
European Society of Human Reproduction and Embryology

Reproductive options for transsexuals

The right to procreate

In modern reproductive medicine it is generally accepted that
every person has the right to procreate (Robertson, 1987;
Schenker and Eisenberg, 1997). For the transsexual patient
this does not seem obvious. The problem is that hormonal and/
or surgical treatments have rendered procreation biologically
impossible. In daily infertility practice, however, there is
another example where procreation is impossible by natural
means. Reproduction within lesbian couples is nowadays more
and more accepted and both simple donor inseminations and
cross-over IVF (one woman provides the oocytes, which after
fertilization in vitro are transferred to her partner) are performed
to help fulfil the wish for children of lesbian women. Many
studies have shown that the children are developing in exactly
the same way as children from heterosexual parents (Brewaeys
et al., 1997; Chan et al., 1998) and this has made homosexual
procreation socially and medically more acceptable. The argument that the transitioning transsexual patient has deliberately
chosen to abandon his or her reproductive potential, is of the
same nature as saying that a woman becomes a lesbian by
choice. If we accept that lesbianism is not a matter of choice
and we accept that lesbian mothers-to-be may well be helped
with their wish for children, the same should apply to transsexual people.
In short we will discuss the various theoretical options that
are available. It is worthwhile to mention that although most
transsexual people will form heterosexual relationships after
transition, many will not, illustrating the well known fact that
sexual orientation and gender identity are quite different
entities. Therefore, not all options are available for all transsexual people alike.
Sperm banking in transsexual women (male-to-female
transsexual patients)
It is well known that feminizing hormonal therapy will induce
hypospermatogenesis in transsexual women, and ultimately
will lead to azoospermia (Schulze, 1988; Lubbert et al., 1992).
This azoospermia may be considered irreversible after some
time, and furthermore gender reassignment surgery with
removal of the testes obviously leads to irreversible sterility.
The only option, therefore, is to perform sperm preservation
by freezing a number of semen samples, preferably prior to
starting hormonal therapy. This banked spermatozoa can then
possibly be used later to inseminate a female partner if the
quality is good, or else be used to perform IVF.
In case of a future male partner the situation is the same as
with homosexual men today, and there is little help available
except when an oocyte donor and surrogate mother are
involved. Since many transsexual women are, however, sexually oriented towards women after transition (and therefore
identify as lesbians), sperm banking should routinely be
offered to people considering hormonal and/or surgical gender
reassignment treatment. Any man undergoing a treatment that
will damage his reproductive potential (such as chemo- or
radiotherapy for a malignancy) is now offered the opportunity
to bank spermatozoa, and the transsexual woman should be
no exception to this.

Transsexual men
For transsexual men the same principles apply. Masculinizing
hormonal therapy will lead to a reversible amenorrhea but
ovarian follicles will remain in place. There is some discussion
as to whether this leads to a condition similar to polycystic
ovarian syndrome, (Pache et al., 1991). Of course castration
will provoke irreversible ovarian failure. To preserve procreational potential three options are available: oocyte banking,
embryo banking and ovarian tissue banking. We will only
briefly discuss these options, since their technicalities do not
belong to the scope of this paper.
Oocyte banking
Oocyte banking requires hormonal stimulation and oocyte
retrieval (as for IVF) and subsequent freezing of the oocytes.
Although this option would be very interesting, mature oocytes
seem very vulnerable to chromosomal damage by the freezing
and thawing process. The very poor survival of the oocytes
after thawing, and poor fertilization and implantation results
after IVF still make this a non-realistic strategy. Only a few
births have been reported in the world (Chen, 1986) and
oocyte banking besides would also require the use of donor
spermatozoa and a recipient uterus of a future female partner
on one hand, or a surrogate mother in case of a male partner.
The latter case would allow the couple to have their own
genetic child.
Embryo banking
Embryo banking requires hormonal stimulation and oocyte
retrieval (as for oocyte banking or IVF) and it also requires
spermatozoa from a male partner (or donor) with subsequent
freezing of the embryos. Embryo freezing is now a routine
procedure in IVF and yields reasonably good results. Of course
it also would require a recipient uterus (female partner or
surrogate mother).
Ovarian tissue banking
Ovarian tissue banking probably has the most potential for the
future and is already being used for women who undergo
chemo- or radiotherapy for a malignant disease. Ovarian tissue
banking requires no hormonal stimulation nor IVF, and is
technically as easy as sperm freezing. Through means of a
laparoscopy ovarian tissue can be removed, and the ovaries
retain usable follicles even after hormonal therapy (Van den
Broecke et al., 2000), which implies that removal of ovarian
tissue can well be performed at the time of oophorectomy.
Ovarian tissue banking would also require donor spermatozoa and a recipient uterus of a future female partner or a
surrogate mother in case of a male partner. The problem of
ovarian tissue banking is not the freezing but the question of
what to do with the tissue after thawing. One has the option
to graft the ovarian tissue into the patient himself (Shaw et al.,
2000) (of course this is not an option for transsexual men), in
another patient (leading to possible problems of immune
rejection) or in another animal (such as the mouse, but here
613

P.De Sutter

may arise some serious ethical objections). In these three

scenarios follicular growth and ovulation should still be induced
(Oktay and Karlikaya, 2000) and IVF would be needed to
obtain fertilization and pregnancy. As another possibility,
in-vitro culture of the tissue fragments, with follicular growth
and oocyte maturation in vitro still seems to lead to poor
results so far (Smitz and Cortvrindt, 1999) and intermediate
approaches are being explored, combining grafting and
in-vitro maturation (Liu et al., 2000). So, although ovarian
tissue banking seems to be the option to choose, much research
will still be needed to bring this in practice for transsexual men.
The future
In the future there may be other asexual ways of procreation
awaiting us. Since the birth of Dolly it has been shown to be
possible to obtain an individual starting from an adult cell
(Bryan, 1998; Solter, 1998; Wolf et al., 1998). Many other
animal species have already been cloned and theoretically the
human species will probably not be difficult to clone either.
Although cloning may offer great potential to medicine in
general and may have many useful applications, reproductive
cloning (reproducing a copy of a given individual) probably
does not seem of interest (Jones and Cohen, 1999). Indeed,
no two clones would be really identical and at best one
could obtain similarities such as the ones that exist between
monozygotic twins raised at different times and in different
places. Although a remote possible application of reproductive
cloning would theoretically be the creation of chimeras from
two different cloned embryos, so that an individual arises
consisting of the genetic make-up of two different individuals
(Boediono et al., 1999), it is not to be expected that such a
strategy will readily be admissible to society.
Conclusion
In conclusion, several reproductive options to help transsexual
people fulfil their desire for a child are already technically
feasible, or will soon be available The medical world, legislation and society at large will need time to accept the concept
of transsexual reproduction and allow treatment. We think,
however, that sperm and ovarian tissue-banking should now
be discussed and offered to transsexual people undergoing
gender reassignment therapy, so that future treatment may be
possible if wanted. Experience with lesbian couples shows
that when new techniques are available, new treatment options
are sought and offered (Hodgen, 1988), and there is no
reason why transsexual people should be refused these new
possibilities.

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