If you are LGBTQIA+ and want to grow your family, a growing range of artificial reproductive technologies (ART) are available to help you, including intrauterine insemination (IUI), in vitro fertilization (IVF), and surrogacy. Below, we’ll detail some options you can consider, as well as fertility preservation options and links to organizations that connect and support LGBTQIA+ parents.

What fertility options are available for gay men, lesbian women, transgender individuals, and other LGBTQIA+ people?

The technologies that are best for you depend on whether you and your partner (if you have one) have ovaries, testes, or both.

- If both of you have ovaries:

Donor sperm can help you become pregnant, either through intrauterine insemination (IUI) or in vitro fertilization (IVF). (Click here to learn the difference between the two!) Some couples choose to do reciprocal IVF, in which one partner undergoes ovarian stimulation to retrieve eggs, and the other partner undergoes an embryo transfer with the resulting embryos.

- If both of you have testes:

Surrogacy that uses donor eggs can be expensive, but it will allow you to have biological children. You can choose which partner will provide the sperm, you can split the eggs between the two sperm providers, or you can mix your and your partner’s sperm before fertilization.

- If one of you has ovaries and the other has testes:

You can choose to conceive naturally (without medical help), or use IUI or IVF so the partner with a uterus can get pregnant.

- If you are pursuing single parenthood by choice:

If you have ovaries and a uterus, you can pursue pregnancy with a sperm donor on the timeline that’s right for you! If you have testes, then surrogacy with a gestational carrier and egg donor is an option. Both options enable you to grow the family you wish for!

You may wish to seek out a fertility center with a history of caring for LGBTQIA+ patients, as they may be better able to keep you feeling comfortable and understood throughout the process. This can be as simple as talking to LGBTQIA+ friends in your area who have undergone fertility treatment and finding out about their experience with their fertility clinic. You can also call several fertility clinics directly to ask about their history taking care of LGBTQIA+ patients, find out whether they have established relationships with sperm or egg banks, and/or ask if they make a point to offer gender-affirming care.

How do I preserve my fertility before gender-affirming surgery/medication?

If you plan to begin gender-affirming hormone treatment or surgery before having children, and your treatment may affect your reproductive system, there are ways you can preserve your fertility beforehand (1). Sperm freezing, egg freezing, and embryo freezing are all options you can consider. While the cost of egg retrieval, embryo creation, and/or cryopreservation fees can be expensive, there are organizations specifically geared toward LGBTQIA+ parents-to-be that may be able to help with those costs. If you have ovaries and/or a uterus and you plan to have gender-affirming bottom surgery, you can also talk with your clinician about options for preserving the function of these organs if you are considering having children later in life.

It’s important to note that if you are a trans or non-binary person who is not planning on taking hormones or having surgery, and you are considering having children later on, it’s important to care for your reproductive system. Finding a clinician who affirms your gender identity and is sensitive to potential body dysphoria can make a big difference in helping you maintain the health of your body and flag any issues that may make it difficult to conceive. To find healthcare professionals who are LGBTQIA+ friendly, both the World Professional Organization for Transgender Health and the LGBTQ+ Healthcare Directory have directories that allow you to search based on where you live.

Can I still have children if I have already started gender-affirming hormone treatment or surgery?

This can be a tender area, since preserving your fertility may not have been a top priority when you began gender-affirming treatment. Today, clinicians are increasingly understanding the importance of fertility-preservation counseling before beginning medications or surgeries that could affect a person’s ability to have biological children later in life (2).

It may reassure you to know that many trans and non-binary people who have pursued gender-affirming treatment later were able to have biological children. However, this will be specific to the hormone medications and surgery you have received and your own body.

- If you had surgery:

Whether you will be able to have biological children or carry a pregnancy depends on the surgery that you had. Many types of gender-affirming surgeries – such as facial reconstructive surgery or chest “top” surgery – do not affect your reproductive organs, and you can try to conceive either naturally or through assisted reproductive technologies.

If you had a gender-affirming lower-body surgery that involved an orchiectomy (removal of the testes) or oophorectomy (removal of the ovaries) before freezing your sperm, eggs, or embryos, then you will not be able to have biological children. If you had surgery to remove your ovaries but not your uterus, you may be able to carry a pregnancy, either using eggs retrieved before your oophorectomy or with donor eggs.

- If you had gender-affirming hormone treatment:

There’s still a lot we don’t know about how gender-affirming hormone treatment affects fertility long term. Initial evidence shows that fertility can return in many cases after stopping hormone treatment, though much more research is needed to understand how quickly fertility declines after starting hormone treatment and to what degree fertility returns after pausing or stopping hormone treatment.

• If you take testosterone: The initial research is promising, even if the cohort studied is quite small. A number of small studies – including a small study conducted in 2019 (3) and another study conducted in 2022 (4) – have shown that female-to-male transgender people who had already begun testosterone therapy had success with fertility treatment when compared to a cisgender population. Because conception depends on the menstrual cycle (whether or not you undergo IVF), most people taking testosterone will need to stop taking hormone medications in order to restore a menstrual cycle, which usually takes 3-6 months. Since we don’t know how testosterone affects pregnancy, if you are the one getting pregnant, you will not be able to resume testosterone until after birth.

• If you take estrogen and/or androgen blockers: There is so little research on the effect of estrogen on the ability to produce sperm that it is difficult to make any conclusions. We can cautiously share some initial findings. There’s some evidence that estrogen therapy affects the ability to produce sperm, possibly permanently in some cases, though the degree to which it affects sperm varies greatly. Additionally, a study conducted in Sweden in 2021 found that transgender women who underwent estrogen therapy experienced a high occurrence of sperm abnormalities and a lower sperm count (6). Perhaps the only conclusion we can make so far is that the restoration of sperm production has occurred to some degree for some people after stopping taking estrogen for some period of time. It is difficult to share discouraging findings from so little research: much more research is needed to understand how, why, when, how much, and for whom estrogen therapy affects sperm. What we may be able to say is that if you decide to try to restore sperm production: it has been possible, you should plan to be off estrogen for many months, and it may not result in a positive outcome.

It’s important to note that gender-affirming care is incredibly important toward your health. Even when you very much want to become a biological parent, it can be a difficult transition to stop taking hormones to try to restore function to your reproductive system. Complex feelings about this may arise as you decide the right path for yourself, and especially if you discontinue taking medications that have a significant impact on your well being.

If you decide to stop taking gender-affirming hormones in order to pursue biological parenthood, getting support for your mental health as you experience changes in your body can help you through treatment, whether by seeing a therapist, finding trans or non-binary people (whether in-person or online) who have also pursued biological parenthood, or having a trusted shoulder to lean on in a friend or family member.

What are some organizations that connect and support LGBTQIA+ parents?

While you may be able to find a support group locally, we found that these two sites had resources for LGBTQIA+ people hoping to share experiences:

• Family Equality - This organization, supported by the LGBTQ+ Perinatal Wellness Center and Resolve New England, has a bi-weekly peer support space online for anyone LGBTQ+ who is pursuing parenthood through pregnancy.

• Resolve - This organization has a number of virtual and in-person support groups for LGBTQIA+ people pursuing parenthood or experiencing infertility.

All families are beautiful and all people deserve to build the family they desire. At Alife, we will always support LGBTQIA+ people in their pursuit of parenthood.