ASRM Today: Fertility Preservation and Gender-Affirming Hormone Therapy

In this episode of ASRM Today, host Jeffrey Hayes and co-host Dr. Lowell Ku continue their season-long exploration of LGBTQ+ issues in reproductive medicine with a conversation on fertility preservation and gender-affirming hormone therapy. Joinong them are Dr. Molly Moravek of Henry Ford Health and Dr. Randi Goldman of Northwell Fertility, both leaders in fertility preservation, oncofertility, and LGBTQ+ reproductive care. Together, they explore the options available to transgender and gender-diverse patients who may wish to preserve fertility before or during gender-affirming treatment. The discussion addresses common misconceptions about hormone therapy and fertility, the emotional and logistical challenges patients may face, and the importance of inclusive, affirming care throughout the process. Drs. Mravek and Goldman also share practical insights on counseling patients, reducing barriers to care, and creating clinical environments where LGBTQ+ individuals feel supported, respected, and empowered in their family building decisions. 

Welcome to ASRM Today, a podcast that takes a deeper dive into the current topics in reproductive medicine. I am Jeffrey Hayes and today on the show we continue our season-long discussion of LGBTQ plus issues in reproductive medicine, this time diving into some of the questions that surround the topic of fertility preservation and HRT. Joining me for this discussion is my co-host Dr. Lowell Kuh.

How are you today, sir? Hey everyone, glad to be here and thank you guys for joining us today. Wonderful. Our guests today are Dr. Molly Moravec, who is the Division Director of Reproductive Endocrinology and Infertility in the Department of Women's Health Services at Henry Ford Health in Detroit, Michigan, and is a professor of obstetrics, gynecology, and reproductive biology at Michigan State University.

Dr. Moravec received her bachelor's degree at the University of Michigan, then attended the University of Michigan Medical School, where she received both her medical degree and a master's degree in public health. She completed her residency in obstetrics and gynecology at the University of Michigan and her fellowship in reproductive endocrinology and infertility at Northwestern University, where she also received a master's degree in clinical investigation. In addition to her general fertility practice, Dr. Moravec has a special interest in fertility preservation and currently serves as the Executive Director of the Oncofertility Consortium.

She also has a clinical and research interest in family building for LGBTQIA plus individuals. She has a mouse model in which she has studied reproductive effects of gender-affirming hormones and is a prior chair of the ASRM LGBTQ special interest group. Molly, welcome back to ASRM today.

It's been a few years. It has been a few years. Thank you so much.

Also with us is Dr. Randy Goldman, who is a reproductive health and infertility specialist at Northwell Fertility and the program director for their reproductive endocrinology and infertility fellowship programs. She is an associate professor at the Donald and Barbara Zucker School of Medicine at Hofstra Northwell and is the chairperson for the patient experience committee for Northwell Health Physician Partners. Dr. Goldman's clinical and research interests span broad range of reproductive health topics, including fertility preservation, oncofertility, and fertility treatment for the LGBTQ plus community.

Welcome to the show, Randy. Thanks so much. Wonderful.

Dr. Q, would you like to kick us off with a question? Yeah, yeah. Thank you both for being here. We are absolutely delighted and honored to have you both.

We know that you guys are experts in this field and we're so excited to have you here. So let's start it off. Our audience are physicians, infertility doctors, nurse practitioners, nurses.

So we have a wide variety in our audience, but how do fertility preservation options differ for LGBTQ plus patients and what factors should be discussed before starting gender affirming hormone therapy? I'm happy to take this one. So I think that the easy answer is they really don't differ all that much. The options don't really differ.

They're honestly mostly the same. Sperm freezing, egg freezing, embryo freezing, sometimes tissue freezing are all valid options depending on what organs, what reproductive organs a person is born with. I think what can vary is the timing and the timing of it in kind of relation to if they're potentially going to be starting gender affirming care.

So for trans patients and for non-binary patients, we tend to have this conversation prior to initiation of hormones or surgery. And the key points are whether they want to potentially have a genetic child in the future, how soon they're planning on starting hormone therapy, whether they're open to potentially delaying that depending on what their plans are and the possibility that they might need to in the future stop hormones to later use their gametes depending on who their partner is and their plans are for the future. Yeah.

Lowell, the only thing I would add to that is prior to starting hormones, I think it's really important that we disclose to our patients that we don't actually know that they have to do this before they start hormones. There is conflicting data on the effects of doing an egg stimulation or an oocyte, sorry, retrieval, an ovarian stimulation while on testosterone. There's certainly a lot of encouraging reports about possibly stopping testosterone to do it.

The data around gender affirming estradiol is a little less optimistic, but we still think you can have recovery if patients are willing to stop. And so I think particularly with the younger patients, I served mostly adult patients in prescribing gender affirming hormones, but every now and then would see someone for a fertility consult that was 14 or 15 and just really was not ready to think about something like freezing eggs. So I think it's also important that they know while we can't promise them that five years of testosterone isn't going to adversely affect their fertility chances if we freeze eggs later, it also doesn't necessarily mean that they've lost their chance for future fertility.

Would you say that those are common misconceptions that patients might have coming into the office? Yeah. I think there's two extremes. I think one thing that some people think, which is what Molly is referring to, is that hormones will definitely make me permanently infertile.

And we know that that's actually not true most of the time. Most of the time it doesn't do that. The other misconception is that I'm on hormones, so I can't get pregnant or I can't cause a pregnancy.

That's also, I think, a very big misconception. It doesn't act as contraception. Obviously with surgical intervention, removing of an ovary, for example, or both ovaries, that's going to result in infertility.

But a lot of the medications don't. So hormones can potentially reduce fertility in the future. Sometimes that could be significant.

Usually it's not. It's not predictable and it's also not contraception. So I think it's really important to note that in the past, I think we were a little bit more, I think, hesitant about telling patients that they were likely going to maintain their fertility in the future, say if they're on T and then stop it at a later date.

But the data is increasingly reassuring that it usually doesn't cause permanent infertility. And like Molly mentioned, there is a lot of newer data that suggests that you don't even necessarily have to stop T to do ovarian stimulation. And I know that in my practice, I counsel my patients about the option to continue it.

Of course, there's lesser outcome data in that situation, but certainly an option. Jeff, I would say we see it both ways. In the youth that I would see for fertility preservation consults, and Randy, I'm guessing you have a similar experience.

It's often that someone told them they basically have to do this consult in order to get their hormones. And so they are just checking a box. And sometimes it's for their parents.

Sometimes it's for the prescribing doctor, but basically just checking a box because someone told them they had to do this. They haven't even really thought about fertility because they're 15. All the time.

I'll say the other. Yeah, exactly. Yeah.

I mean, and then I feel badly because I almost feel like a gatekeeper, which I'm, you know, that is not supposed to be our role. I think the other extreme would be the patients who no one even mentioned it to them. And I think that's a really hard thing to talk about as well.

Particularly someone who's been on hormones, just say for over a decade, because those are the patients who have, you know, pretty fully transitioned coming off of estrogen may not be as accessible to them anymore or as psychologically safe for them anymore, frankly. And so I think in both extremes, there's a lot more education that needs to be done, not just of our patients, but honestly, the physicians prescribing hormones too. You know, thank you.

Yeah, it's so important about counseling. You guys had mentioned that you guys do a ton of counseling, which is so important and so vital and educating as well. And that patients sometimes don't know what they don't know.

Right. And so it's good to really teach them about their potential journey. So when you do counsel and you see these patients, what sort of barriers, whether it's financial, emotional or systemic to LGBTQ plus patients face when accessing fertility preservations? And what sort of strategies do you guys use to help reduce any of those barriers? I was just going to say, I talk a lot about, I guess, my own personal shortcomings when it came to this, when I first started, because, you know, I was not only a reproductive endocrinologist, but I actually was a gender affirming hormone prescriber.

And so I just assumed incorrectly, you know, that I could put on my website that I was LGBTQ friendly and that I prescribed gender affirming hormones and that that so clearly meant, you know, that patients were safe with me and with us, which is actually the important point. And then I had a colleague identifies as non-binary, who really made me realize how wrong I am, that that patient's impression starts when they look at your website. And if you don't have pictures of non-heterosexual couples, they don't know whether or not they're safe in your clinic.

If you don't have a section dedicated to LGBTQ health, if you walk in the clinic door and the clerk doesn't know what to do with he, him pronouns, that patient no longer feels necessarily safer welcome. And so I think what it really impressed upon me was that it's not enough to just be affirming yourself. You need to make sure that everything about your practice and everyone in it is affirming and is educated to make our LGBTQ patients and particularly our transgender and gender diverse patients understand that they are welcome and affirmed in your space, not just in your personal presence.

Yeah, a hundred. I could not agree with that more. Everything that Molly just said, I think not all clinics are set up to be inclusive or knowledgeable, even though we want them to necessarily be.

And there are so many steps before that patient is in your office and in front of you. All that matters, right? Me and Molly, we're not the first impression, right? Maybe when they Google us, they see LGBT research, et cetera, but it's everything that comes before that is incredibly important. It takes time, right? It takes time to educate staff, to educate my trainees, my fellows.

We focus a lot about inclusivity and knowing who the patient is before they walk into the room and also assuming nothing, right? We should not assume anything about patients when they walk in, including that they necessarily want kids because like Molly said, they might just be in your office because they needed to check off a box before they got their treatment. Not everyone wants biological kids. Not everyone who is born with a uterus wants to carry a pregnancy.

I think using the patient's language is really, really critical because it helps to give them some control, right? A lot of times they're making very kind of big life decisions and it can feel like they don't have a lot of control. And also just acknowledging that the process can be dysphoria inducing, which is really, I think, specific to the LGBTQ plus population. It's not going to be the same for a cis woman doing egg freezing.

So I think that itself can act as a barrier, right? Lack of knowledge from the patient standpoint or the staff or team standpoint can be a major barrier. And we can't talk about fertility preservation, I think, without mentioning the fact that cost is a barrier for anybody or can be a barrier for anybody. And while I might consider fertility preservation prior to gender affirming care to be medically indicated or necessary as an option, insurance companies might not feel the same way, right? If it's not a cancer diagnosis, it might not be considered medically indicated.

There's different thresholds for that as well. But I think cost is a major barrier for anybody thinking about fertility care for delayed childbearing, regardless of the reason. When you were talking about people who just come in and check the box, right? Now, opposed to that, of course, people who come in and want to start a family, want to do all these things, do either of you have a specific way you go about that you can discuss fertility options that may feel sort of, if they begin to feel sort of emotionally complex or uncomfortable? I think it is so important to speak in language that the patient is comfortable with.

And I'm so glad that Randy brought that up as a barrier, but also to your point, Jeff, I think it is so important when having these conversations, because really, what you need to get to the bottom of is where am I going to get the gametes to make this baby, right? Like from a scientific standpoint, I don't care where the eggs are coming from, where the sperm is coming from, which uterus we're using, as long as you get the child that you want at the end. And so being able to have that conversation in a way that is comfortable and affirming for the patient is really important. And in our clinic, or actually my last clinic, we ran into some trouble with this, where people would say, like, well, I should be able to use the anatomical terms, right? Like, I should be able to say ovary to a patient who has ovaries, because that is an anatomical term, and they need to get used to it.

And I guess, I don't know, I used to have a mentor and say, would you rather be right or do right? And sure, yeah, ovary is the anatomical term. But does it really matter? Like that might be on your intake form, but do you have to keep saying that to the patient when you know it makes them uncomfortable? And so I am always very quick to ask, like, how would you like me to refer to your reproductive organs? And your partner's there, and as Randy said, like, making no assumptions based on what that partner looks like, what organs they have. How would you like me to refer to your organs? And who's willing to do what? You know, just because you make sperm doesn't mean you're willing to use it to create a baby.

And so I think just having all those questions in terms that are comfortable for the patient, and are asked in a truly curious way, as opposed to an assuming or judgmental way, gets you miles further in getting this patient the family they need than to restrict your own opinions on proper terms. Absolutely. You know, the, you have to use terminology that the patient is comfortable with.

And the only way that you're going to know is to is by asking the question. So I probably ask a lot of questions. And I think that that I hope that that makes the patients feel more comfortable.

And I do this, I think, for all patients, you know, if there's anything that makes you uncomfortable, please let me know, just saying that and opening it up to the patient, gives them that open door to be truthful about how they're feeling about things. And they'll be more willing to share if there is something that that happened, right? Like if, I'll give you an example. So on our ultrasound machines in our office, the default for, you know, sex is the F, right? It defaults to that.

I'll sometimes tell the patient this up front, if you notice that it says this, instead of what you want it to be, just, you know, please say the word. It's not always that there's something that's an intentional thing, but that's something that can make a patient very dysphoric, right? It's not their identity. So opening up the these are the potential things just allows them the option to, to tell us if there's something that needs to be optimized, and better for them.

That's fantastic. You know, for physicians like me, who want to make sure that I'm saying the proper language and making sure that I'm making these types, the LGBTQ types of individuals who have specific type of language that they desire, where do I find this sort of information to make sure that I am speaking properly, appropriately, kindly, with respect? Is this something where I might be able to ask someone or what do you guys recommend? I mean, I'll tell you that with our paperwork, which is important, right? Oftentimes patients are getting paperwork before they even come into the office, have more free text than assuming anything, right? So for example, where it says pronouns, we don't list the options, we just have the patient type in what they want. And that's an easy way of knowing exactly what it is without having to, you know, give a general list.

So that's, that's the way that I approach it. Oftentimes I know a lot about the patient before they walk in the door because of some of that paperwork, but paperwork is always a challenge because it tends to be, you know, leftover from, you know, over a decade ago. So I think it just requires somebody to take a look at it and make sure that it's, we're doing the best that we can by our patients and in the written communication as well.

And oftentimes that translates to the verbal communication. I love the question that you had, like, you know, if there's anything that I say that makes you uncomfortable, please let me know. I love that idea that, you know, let's give the the power to the patient and make them realize that yes, absolutely we're a team.

And if I'm doing something that doesn't make you feel comfortable, please let me know. I absolutely will change my behavior. I think it's important for the patients to know that, that you are there to help them reach their goals with what they're there for.

And in our offices, it's for the potential for fertility preservation or attempting conception or to contribute a gamete, right? So I think it's important for them to know that we share the same goal, which is to help them, you know, reach theirs from the parenthood standpoint. And, you know, I typically have this conversation with most people and that there are many paths toward having a family, having a baby, no one right way. And so we really sort of talk about the parts that we have, the parts we want to use and what we might need from outside.

And not to put in a plug for ASRM on the ASRM podcast, but Randy and I both actually worked on a document about how to make your clinic more friendly toward LGBTQIA plus populations and gender inclusive language, inclusive language in general, and then separate documents specifically about fertility and fertility preservation in these populations. So I think that is a great resource. And then people looking for other high quality resources, because as we all know, you can find just about anything on the internet.

It doesn't always mean it's good, but I think UCSF has a website dedicated to this as well that is quite good, as does Fenway and as does WPATH, which is, gosh, the World Professional Association for Transgender Health. They're excellent. I'm glad you said that plug, Molly.

I'll further the plug. You can go to www.asrm.org, or you can go over to fertility and sterility to explore more about what we are discussing. Unfortunately, we're out of time for today.

I want to thank my guests. Dr. Randy Goldman, thank you so much for being here. Thank you.

It was an honor. And Dr. Molly Moravec, thank you so much for being here. Thank you.

Wonderful. As always, if you have questions for us, you can email us asrm at asrm.org. We would appreciate if you would hit the subscribe button when you listen to the show so that way when new episodes drop, you don't have to worry about it. It just magically shows up in your phone or on your computer or however you access these things.

And we greatly, of course, appreciate everyone in our audience. And until next time, I'm Jeffrey Hayes. And I'm Lowell Coon.

This is ASRM Today. This concludes this episode of ASRM Today. For show notes, author information, and discussions, go to asrmtoday.org. This material is copyrighted by the American Society for Reproductive Medicine and may not be reproduced or used without express consent from ASRM.

ASRM Today series podcasts are supported in part by the ASRM Corporate Member Council. The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and its affiliates. These are provided as a source of general information and are not a substitute for consultation with a physician.