Fertility
Are you starting hormone treatment and/or genital surgery? Then it is important to first consider any future wish to have children of your own and to preserve your fertility.
Options for preserving your fertility
There are several ways to fulfil your future desire to have children of your own. The options available to you depend on your wishes and the fertility of any current or future partner. If you would like a biological child, then there are three ways of preserving your fertility and increasing your chances of biological parenthood:
- Temporarily retaining your genitalia;
- freezing egg cells (= oocyte cryopreservation) or embryos;
- freezing of ovarian tissue (= ovarian tissue cryopreservation).
The figure below shows the anatomy of the female genitalia.
Option 1: temporarily retaining the genitalia
As long as you are in doubt about wanting to have children of your own, preserving the uterus, ovaries and vagina gives you the best chance of maintaining fertility. However, this choice is not suitable for everyone; the dysphoria often concerns particularly these organs. This is different for everyone; you will have to make your own assessment.
Uterus preservation
If you would like to have biological children or carry them, this is possible as long as you retain your uterus and vagina. Although not much is yet known about the long-term effects of testosterone on the uterus, all studies to date are reassuring. You can still decide whether or not to remove these organs at a later date.
Preservation of the ovaries
If you wish to have a biological child, you will need to leave your ovaries in place, as this is where the egg cells are stored. As far as is known today, testosterone has no harmful effect on egg cells. However, if you decide to freeze your eggs, you will have to temporarily stop taking testosterone.
Preservation of the vagina
If you choose to remove your vagina (and uterus) but leave your ovaries, this will reduce your fertility chances, because the ovaries can then only be reached via the abdomen, making it more difficult to check egg cells and perform a follicular puncture. it also involves more risk and, usually, fewer eggs are found.
Option 2: freezing egg cells (= oocyte cryopreservation) or embryos
There are several moments in time for deciding to have your egg cells frozen:
- Before starting testosterone treatment;
- At a later stage — for example, when you are actually ready to use the egg cells;
- Before the operation to have your ovaries removed.
As far as is known at present, the use of testosterone will not impact the quantity and quality of the egg cells in the body. For points two and three, you must first stop using testosterone three months prior to such as procedure. Hormone stimulation precedes the harvesting of egg cells. These hormones stimulate egg cell growth.
If you have a steady partner (with sperm cells) with whom you would like to have children, it is also possible to fertilise your egg cells in a laboratory (IVF treatment) and then freeze the embryos.
Ovarian stimulation
Only mature egg cells can be frozen. To achieve mature egg cells, you will need daily hormone injections. This will take 5 to 6 weeks. In the meantime, the physician will check the growth of the egg cells with a vaginal — internal — ultrasound scan.
If there are enough mature egg cells, they are harvested via the vagina, using a needle (follicular puncture). See the image below. This is done using pain relief. Subsequently, the egg cells are frozen immediately.
Possible physical disadvantages/side effects
- The treatment may cause feelings of dysphoria.
- The injections may cause side effects, most commonly headaches and fatigue. The hormonal fluctuations may also cause psychological complaints.
- The hormones and growth of the ovaries may cause you to feel bloated or give abdominal pain.
- Injecting yourself with the hormones can be painful.
- Despite having pain relief, follicular puncture can be unpleasant.
If you have experienced physical changes due to testosterone use, such as beard growth and a lower voice, these changes will remain. If you still have your breasts, they may temporarily become more sensitive. You may also experience vaginal bleeding as a result of the hormonal changes.
Costs
The costs of freezing are approximately EUR 2,000 to 3,000; this will usually be covered by your health insurance. We recommend that you check with your health insurance company before starting treatment.
The costs of storing egg cells are around EUR 60, per year. You must pay this yourself.
Option 3: Freezing of ovarian tissue (= ovarian tissue cryopreservation)
If preserving the ovaries or freezing the egg cells is not an option for you, you may choose to freeze ovarian tissue. This is an experimental treatment which may in the future enable maturing immature egg cells in a laboratory. The ovarian tissue to be frozen is removed during the surgical procedure to remove the ovaries.
Procedure for removing ovaries and freezing tissue
The ovaries are removed through keyhole surgery (i.e. laparoscopy) under general anaesthesia. This is usually a combined surgery: the uterus and/or vagina are removed, as well. There is a small risk of complications during and after keyhole surgery, such as damage to the urinary tract, bowel or blood vessels, the occurrence of infections, or thrombosis.
After removal, the outer layer of the ovarian tissue is cut into small pieces. These are then frozen and can remain stored for years. However, by freezing and later defrosting them, some of the egg cells will become damaged.
Experimental treatment
The freezing of ovarian tissue is still an experimental procedure. There is ongoing research into the possibilities of in-vitro maturation (maturing immature egg cells in the laboratory so that they become usable egg cells). This procedure may be a possibility in the future, but it is not at present.
Costs
If you opt to freeze ovarian tissue, this will not change the operation that is already planned and, therefore, there are no additional costs. However, you will have to pay transportation costs (approximately EUR 400 once) and storage costs (approximately EUR 60, per year). These costs are not covered by health insurance.
Fertility preservation decision tool
On the advantages and disadvantages page (disclaimer: only available in Dutch), you will find additional information about fertility preservation and the arguments in favour and against each of the genital surgical procedures.
Accessibility to egg cells
You will not be able to immediately access your frozen egg cells. At the time when a pregnancy would be desired, the medical, ethical and legal aspects of the pregnancy are reviewed and weighed. The interest of the unborn child takes on a central position in the decision.
Sperm cell donation
If you would like to make use of sperm cell donation — for example, because you do not have a partner who can provide egg cell fertilisation — then you can choose to look for someone yourself, for example amongst your friends, or you may choose a sperm bank. In the latter case, the treatment (i.e. artificial insemination) will take place in a hospital. You can read more about obtaining data on both sperm cell and egg cell donation from the information pages of the Dutch Government.
Fulfilling the desire to have children
If you have a desire to have children, there are several ways to accommodate that wish. For example, you may consider carrying a biological child. Perhaps you can and want to carry it yourself, or maybe you have a partner who would like to do so. If neither option is available, surrogacy outside your relationship may be a possibility. In addition to having a biological child, you could also think about adopting one.
This text was edited on 1-8-2022
Next Step
We recommend that you go through all the information step by step to get a complete picture of the different treatment options and the process around them!
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Preparing for the genital operation
To be eligible for genital surgery, you must be well informed and meet a number of criteria. A summary of the various genital surgeries for masculinisation are described below, followed by the related criteria.
