Fertility care and family building for LGBTQ+ individuals: a committee opinion

In the general population, close to half of pregnancies are unplanned, which is in stark contrast to the lesbian, gay, bisexual, transgender, queer (LGBTQ+) community, where family building is often a complex, sociomedical process, often involving a fertility clinic, psychoeducational counseling, a reproductive attorney, and unique Food and Drug Administration (FDA) requirements. Although the innate desire for genetic relatedness often remains in LGBTQ+ patient populations, the use of donor gametes is typically expected, unlike in other patient populations, where this may be used as an option of last resort (1). General infectious disease screening and testing, genetic counseling, and psychoeducational counseling for those using donor gametes or gestational carriers are described in separate American Society for Reproductive Medicine (ASRM) documents (2, 3). This document will review special considerations for LGBTQ+ family building to supplement those existing ASRM documents.

HISTORY OF LGBTQ+ FAMILY BUILDING

The history of LGBTQ+ family building in the United States is discussed at length in a separate publication (1). Figure 1 provides a historical and clinical context for seven key paradigm shifts to illustrate the evolution of LGBTQ+ family building. Most recently, in 2023, the new ASRM definition of infertility includes individuals who work with donor gametes and/or gestational carriers, as well as single parents by choice, among others. It is important to recognize that insurance companies may have their own criteria when determining coverage (4).

INFECTIOUS DISEASE SCREENING

Although the risk of infection transmission from semen to patients undergoing embryo transfer during assisted reproductive technology (ART) procedures is essentially negligible, some LGBTQ+ subgroups, such as men who have sex with men, are known to have higher rates of sexually transmitted infection (STI) (including human immunodeficiency virus [HIV], cytomegalovirus [CMV], human T-lymphotropic virus [HTLV]) (5–7). Due to a lack of routine data collection on sexual orientation and gender identity, STI rates among various other LGBTQ+ subgroups remain poorly characterized and limited by reporting that only stratifies binary sex (male or female) (8). Furthermore, monogamous, two-person relationships should not be assumed in any patient population, and patients should be counseled on the importance of negative STI screening with repeat testing throughout treatment (9).

HIV

As discussed in a separate ASRM Ethics Committee opinion, there is no ethical reason to withhold fertility services at clinics with the necessary resources to provide care to HIV-infected individuals and to patients who are willing to use recommended risk-reducing strategies (10). Although annual HIV infections among gay or bisexual men have been stable, this subgroup and possibly other LGBTQ+ subgroups remain disproportionately affected by HIV. As a result, clinics that do not offer services to HIV-infected patients disproportionately limit access to this patient population.

MENTAL HEALTH AND PSYCHOEDUCATIONAL COUNSELING

Third-party assisted reproduction is associated with a host of emotions and complex decisions (2, 11). Additionally, it is well known that fertility treatments may cause psychological distress in all patient populations who desire family-building assistance (12). Given that third-party reproduction is routinely used for LGBTQ+ family building, some have raised concerns that a psychoeducational counseling requirement puts undue burden on LGBTQ+ individuals that is not as frequently experienced by heterosexual, cisgender people. Nonetheless, the decision to use third-party Assisted Reproductive Technology (ART) is complex, and all intended parents may benefit from psychosocial education and counseling by a qualified mental health professional (2, 11, 12). When indicated, the ASRM strongly recommends a clinical evaluation by a qualified licensed mental health professional who has received training and education for third-party reproduction, regardless of the patient population. Professionals with specific training in working with LGBTQ+ patients may be valuable for LGBTQ+ intended parents. Although clinicians are aware of these policies, LGBTQ+ patients may assume this is an assessment of their ability to parent. This is due to a long history of uncorroborated claims that outcomes of children of sexual and gender minorities may be negatively impacted due to their parents’ sexual orientation and/or gender identity (13). Clinicians should inform patients that the consultation is educational and not evaluative.

Psychoeducational counseling specific for LGBTQ+ intended parents includes (see ASRM Guidance regarding gamete and embryo donation for universal donor counseling recommendations (2)):

• A clinical interview that explores the intended parent(s)' history of family building efforts as well as coping strategies for these challenges.
• The potential impact of the relationship between the intended parent and any third parties (gamete donors or gestational carriers) and future contact (14).
• An exploration of issues related to directed vs. nonidentified gamete donors now and in the future–discussing pros and cons of choices (15).
• Exploring with intended parents any significant psychological issues that could compromise successful collaboration with all of the outside parties.
• Expectations related to privacy and disclosure to friends and family, and the ongoing coming out process that LGBTQ+ parents will experience.
• Discussion of the medical protocol, scheduling demands, risks of canceled or unsuccessful cycles, number of embryos transferred, multiple pregnancy, multifetal pregnancy reduction, prenatal diagnostic testing, and elective termination.
• When donor gametes or embryos are used, emphasizing to intended parents the importance of disclosure to their children about their genetic origins (14).
• Expectations of disclosure of the gestational carrier and gamete donor’s role to any born child(ren) and the scope of the relationship between the gestational carrier, gamete donors, the intended parent(s), and children after birth.
• Issues that may arise related to gestational and nongestational or biological vs. nonbiological parenting.
• An exploration of familial support or lack thereof, and the emotional toll this can take.
• Exploring homophobia–internalized, systemic, familial, societal, etc., and coping strategies.
• Clinicians should acknowledge that patients may have already faced stigma from friends and family in pursuing family building with or without the use of ART (e.g., choosing in vitro fertilization (IVF) over adoption or fostering) (16–18).

LEGAL CONSIDERATIONS

In addition to psychoeducational counseling, patients requiring third-party reproduction may benefit from legal consultation, depending on their specific situation. Reproductive laws vary from state to state, and consultation with a legal expert in third-party reproduction should be considered by patients. Legal consultation is recommended to explore parental establishment and the protection of the parent(s) (regardless of genetics or biological connection), as well as the need for a legal contract with all third parties.

CARE FOR CISGENDER FEMALE PATIENTS PLANNING TO USE THEIR OWN EGGS AND/OR UTERUS

Individuals whose bodies produce oocytes and/or have a uterus may present for a variety of clinical services, including, but not limited to, therapeutic donor insemination, IVF, or reciprocal IVF. In the absence of indicators of clinically diagnosed infertility, data show that this population is clinically unique, and treatment protocols based on evidence from infertile populations may not improve outcomes for these patients. At the same time, fertility treatments often increase cost and may cause harm (e.g., increased risk of multiples) (19). It is imperative that patients from this population receive clinically appropriate, evidence-based care, which may diverge from routine protocols in the infertility clinic setting.

TESTING TO INFORM DONOR SELECTION

Consideration should be given to the recipient's blood type and Rh factor, particularly for Rh-negative recipients. If the use of donor gametes or embryo(s) poses a risk of Rh incompatibility, recipients should be informed of the obstetric implications of the condition. Notably, with washed sperm samples, CMV does persist in the embryo in animal studies (20, 21). Considering this, as well as other factors, such as matching the partner’s racial or ethnic background, which may limit the pool of appropriate donors for a given family, it is reasonable to inform CMV-negative recipients that there may be a low, but likely negligible risk of transmission from a donor with evidence of past, but not current, CMV infection. Each clinic should have a policy about how patients are informed of any potential risks

MEASURES OF OVARIAN RESERVE

Measures of ovarian reserve, specifically antral follicle count and antim€ ullerianhormone, do not predict the likelihood of pregnancy or miscarriage after donor insemination (22, 23). Rather, patient age is the most clinically relevant factor. Information should be provided to incoming patients regarding the lack of clinical utility and additional cost of these tests, and donor sperm services should not be withheld for patients who decline them.

TUBAL PATENCY

Assessment of tubal patency should be offered but not required for this population. This screening may reassure patients who must incur costs related to donor sperm and insemination. However, in the absence of risk factors for tubal disease (e.g., prior sexually transmitted infection, prior ectopic pregnancy, etc.), and due to the invasive nature of the procedure, it may not be desired by the patient prior to any attempt at conception. Clinicians may defer this assessment until after an agreed-upon number of insemination attempts.

OVARIAN STIMULATION

In patients utilizing donor sperm, ovarian stimulation does not result in a significant increase in ongoing pregnancy rates and increases the risk of multiple pregnancies more than fourfold (19, 24). Patients should be informed of this risk and should be offered natural cycle insemination as the safest, most cost-effective method of medically assisted reproduction, at least in the first three to six cycles.

Insemination Timing

Timing is a key factor in achieving pregnancy with therapeutic donor insemination (TDI). The live birth rate decreases significantly if IUI is performed >19 hours before or after ovulation, which confirms that identifying the time of ovulation is key to IUI success (25, 26). In natural cycle TDI, cumulative live birth rates are comparable or higher when insemination is timed with urinary LH kits rather than ultrasound monitoring and human chorionic gonadotropin (hCG trigger (27, 28). Some patients may opt for cervical mucus observations in combination with urine LH, which is a more reliable indicator of the day of ovulation than LH alone (29). Patients should also be advised that ovulation may occur before, during, or after the urine LH peak, which renders test kits on the market that identify the LH peak less useful than those that identify the onset of the LH surge (30). Patients should be provided with this information, including the comparative costs of each method and any pertinent logistical constraints in the clinic, and allowed to opt for the method they prefer, including the option to self-determine timing for IUI. Efforts should be made in the clinic setting to accommodate access to IUI procedures when indicated for the individual.

Special Considerations for IUI

Same sex female couples should order donor sperm samples in the conceiving partner’s name to avoid confusion at the clinic and aid in data collection for donor recipients. Some patients pursue pregnancy via TDI outside of the direct supervision of a health care provider. Individuals choosing this option should be aware that there may be legal, infectious disease, and genetic implications to doing so.

Success Rates

Ongoing pregnancy and live birth success may be higher in this population compared to cisgender non-LGBTQ+ infertile population (31). However, success is still impacted by age (31, 32). In sharp contrast to cases of unexplained infertility where the probability of success decreases with each cycle attempt, the per-cycle success rate in the TDI population is consistent for up to at least six cycles or more (33, 34). The rate of live birth is higher with intrauterine vs. intracervical insemination (35). Patients should be given accurate information about their likelihood of success with intracervical insemination (ICI), IUI, and IVF, and clinicians should refrain from extrapolating evidence from unexplained infertility to recipients of TDI. Studies report clinical pregnancy in TDI cycles ranging from 12% to 20% per cycle and live birth of 10% to 11% (19, 34, 36). Clinicians should complete a personalized, risk-focused work-up for infertility in the LGBTQ+ community when counseling on success rates.

CONSIDERATIONS FOR IVF/RECIPROCAL-IVF

Some, but not all, same-sex, cisgender female partners may both have a desire to be involved in the conception and/or gestation of their child. One option in IVF cycles involves an FDA-approved device that allows the embryo to be incubated intravaginally prior to embryo transfer, which gives the partner an opportunity to ‘‘gestate’’ the embryo (37). However, in a randomized trial, this device was associated with a relative reduction in good-quality embryo development by 40% (38). Additionally, some families may opt to conceive via reciprocal IVF (R-IVF), in which one partner’s eggs are retrieved and fertilized, and the other partner carries the pregnancy. Although data are limited, overall success rates with this method are high (∼60%) (39). There are reports of a high incidence of twins (14%) when using reciprocal IVF, and single embryo transfer should be recommended according to ASRM embryo transfer guidelines (40, 41). Intended parents in couples who have the desire for both partners to be involved in the reproduction process can be advised that the cumulative live birth rate is 22% higher in R-IVF couples who utilize clinical criteria to select which partner will provide eggs and which partner will carry, compared with autologous IVF/intracytoplasmic sperm injection (ICSI) in the cisgender infertile population (42). A retrospective, multicenter cohort study comparing IVF cycles using autologous oocytes to R-IVF found no differences in reproductive outcomes (i.e., positive pregnancy test, clinical pregnancy, miscarriage, ectopic pregnancy, preterm birth, live birth, gestation age at birth, and newborn weight at birth) (43). In a separate study comparing TDI to R-IVF, there was a similar risk of preeclampsia/hypertension in the R-IVF group. Pregnancy rates were higher for R-IVF (45.3% vs. 21.8%), and the TDI group had a nonsignificant trend of higher multiples (4.7% vs 8.5%) (44). Another study in China found higher success in IVF compared with IUI, but the cost per child was less using donor IUI, although these cost savings may not apply to other countries (45). Various social factors may impact these decisions, and conceiving families should be the ultimate decision-makers in this regard. Clinicians should be aware that literature referring to R-IVF may use alternate terminology, such as co-IVF, intrapartner oocyte donation, shared/comotherhood, and reception of oocytes from partner (46).

CARE FOR CISGENDER MALE PATIENTS PLANNING TO USE THEIR OWN SPERM

For this population, moving forward with family building requires tremendous resources. This may include an reproductive endocrinology and infertility clinic, IVF laboratory, egg donor, gestational carrier, mental health professionals, attorneys, escrow managers, surrogacy agency, and financial resources. At the beginning of the process, intended parent(s) should consider their overall health regarding smoking, alcohol, weight, medication usage, and healthcare maintenance (47). This is especially important since, depending on financial resources, there is often only a single attempt at embryo creation, which represents a significant amount of coordination and expense. Third-party considerations apply to this population, and providers should follow published ASRM recommendations (48).

SPECIAL CONSIDERATIONS

Special Considerations in this population may include and are not limited to dual intended genetic parent (i.e., sperm source) cycles, with or without desire for half genetic siblings, cryopreserving sperm after FDA testing instead of using fresh specimens, and in-depth conversations about the risks, benefits, and alternatives of choosing fresh or frozen eggs (49).

Initial semen analysis should be collected for assessment. If more than one sperm-producing patient desires a genetic link to their offspring, both would need to complete semen analyses to be assessed as a genetic intended parent. Recessive carrier screening should be completed on each person who is choosing to provide sperm. Additionally, any concerns regarding familial genetic risk should be addressed by a genetic counselor. This will be used in matching any proposed egg donor.

Choosing an egg donor is the central part of the family building process, and intended parent(s) often need assistance in choosing an egg donor. Proper consent forms and legal documentation should be in place to move forward with an identified or nonidentified egg donation cycle. Donor matching for couples can be especially challenging, as intended parents often desire a phenotypic and ethnic blend between the two of them. Additionally, if they both are choosing to be genetic parents, ideally, a donor with high enough ovarian reserve to expect sufficient oocytes for split insemination should be considered. Donor oocytes can be accessed from egg banks, as well as through fresh donation. For couples who desire 2–3 genetically related children, multiple oocyte lots may be necessary. Fresh egg donation cycles also need to be considered carefully regarding expected egg yield in the context of sharing one donation cycle between both intended fathers. Sibling oocyte donation may also be considered in order to give the couple a familial genetic link to their offspring. Those situations are unique and require additional psychoeducational counseling and legal agreements. Familial donors should be fully evaluated and screened as all other egg donors in accordance with ASRM guidelines (2).

Management within the IVF laboratory and cycle planning is essential for egg donation cycles. In some cases, the intended parents desire to split the eggs evenly. There needs to be a clear direction on what to do if there is an odd number of eggs. It should be clear that the laboratory will always know the genetic linkage of the embryos through the intended father and the egg source. Additionally, precycle information should be collected as to whether the intended parents wish to have the outcome of fertilization and blastocyst formation defined per genetic intended parent or only reported as a group.

Consideration should be given to cryopreserving an FDA-cleared sperm specimen prior to the start of the egg donation cycle for use in embryo creation for transfer to a gestational carrier. Alternatively, a fresh sample could be used, but there may be hurdles regarding FDA clearance, logistical issues in receiving complete results, and unexpected sexually transmitted diseases that can impede embryo creation. It is important for the clinic to understand that these embryos must first be cleared in accordance with FDA regulation prior to transferring to a gestational carrier (50). FDA ineligibility must be specific and must be disclosed to the gestational carrier, whether this is based on testing or in relation to having male partners in the past 5 years.

Gestational carrier management, as previously discussed, includes additional disclosures to satisfy FDA regulations. This can include an intended father who is HIV positive, an intended father with hepatitis, an intended parent who was previously treated for syphilis and still is positive on the FDA required testing, and other scenarios.

Clinicians should recognize that the extreme associated cost per child (∼$200,000) may be a driver for patient requests for double embryo transfer, but the safety of the gestational carriers and future children should be paramount (1, 51). Single embryo transfer is strongly recommended for all gestational carriers, and the transfer guidelines per the ASRM guidelines should be strictly followed (52).

FERTILITY IN TRANSGENDER & GENDER DIVERSE (TGD) INDIVIDUALS

Gender-affirming hormone replacement therapy (GAHT) is the mainstay of affirming medical care for gender diverse individuals, with the National Transgender Discrimination Survey Report on Health and Health Care reporting previous or planned gender-affirming hormone therapy in ≥80% of transgender people (53–55). Secondary amenorrhea is common in testosterone-treated individuals assigned female at birth (AFAB), with one recent study reporting high rates of anovulation and altered luteal function in transgender men undergoing testosterone replacement therapy (TRT) (56, 57). Moreover, menstrual suppression is often a goal of medical management in transmasculine patients (54, 55). In TGD people assigned male at birth (AMAB), the use of estrogens, progestins, and antiandrogens (e.g., spironolactone and finasteride) has been associated with altered semen analysis parameters (58, 59). Additionally, behaviors such as wearing tight undergarments and tucking (placing and maintaining testes in the inguinal canal, with posterior and perineal positioning of the penis and scrotum) may impair spermatogenesis and have been associated with reduced total motile sperm count (60). In addition to pharmacologic and behavioral variables, gender-affirming surgery, such as gonadectomy and penectomy, prevent medically unassisted conception, whereas hysterectomy limits options for utilization of ART. In light of these gender-affirming treatments, special considerations may exist in the procreative management of TGD people. There should be counseling and planning available for TGD people AFAB regarding possible issues with gender dysphoria for those faced with return or menses, pregnancy, and childbirth. Furthermore, TGD individuals may also experience infertility independent of their gender identity and should be evaluated in alignment with standards of care (61–63).

SPECIAL CONSIDERATIONS FOR PEDIATRIC TGD POPULATIONS

Clinicians should recognize that not everyone is interested in having a child(ren) and, even among those who are, genetic relatedness may not be a priority. Parents and/or guardians of pediatric patients may be more concerned about future family building than patients themselves, who may be more focused on transitioning due to the severity of gender dysphoria. Clinicians must balance patient goals, including a recognition that these goals may change over time, within the context of what is known, as well as theoretical risks of GAHT on gametes, embryogenesis, and pregnancy. This should include a confidential assessment of pediatric patients to inquire about their treatment goals and to provide a private space for counseling.

CONSIDERATIONS FOR TGD INDIVIDUALS AFAB

Modes of conception

TGD persons AFAB who have a retained uterus, regular ovulation, and engage in receptive vaginal intercourse with a sperm-bearing partner may have a medically unassisted pregnancy (64–66). Ovarian stimulation for ovulation induction or superovulation, with or without IUI or TDI, may be an option for transmasculine people with infertility and for those who do not participate in receptive vaginal intercourse with a sperm-producing partner, respectively.

Alternatively, IVF using autologous or donated oocytes in combination with partner or donor sperm may be an option in the setting of infertility or a desire to produce genetically related offspring without personally carrying a pregnancy. In the latter scenario, a gestational carrier or reciprocal IVF may be utilized. Although medically assisted and nonmedically assisted pregnancies have been reported in people who have used testosterone for gender affirmation, the total impact of testosterone on future fertility is not known (67).

Fertility preservation

Surgical removal of gonads leads to sterilization, and GAHT may impair reproductive potential if prior fertility preservation has not been completed. Thus, ASRM, World Professional Association for Transgender Health, and the Endocrine Society all recommend counseling regarding fertility and reproductive options before initiating hormone treatment. Despite these guidelines, the low uptake of fertility preservation in TGD people has been well documented, a phenomenon which has recently been associated with financial barriers (68–72). This may be further complicated by the inability to stimulate mature oocyte production in prepubescent children and adolescents. However, recent data have shown that it is possible to complete ovarian stimulation and fertility preservation for someone on puberty blockade who has not completed puberty (73). Prior to gamete preservation, there should be consideration to completing FDA-required screening, which would expand options for patients to use their genetic material in the future through third-party reproduction (directed donation or through embryo creation and use of a gestational carrier) (11).

Ovarian stimulation protocols

Given the teratogenicity of testosterone, exogenous testosterone should be discontinued prior to any attempts at conception with intent to carry pregnancy. TGD patients are also typically instructed to discontinue exogenous testosterone use prior to initiation of ovarian stimulation for ovulation induction, superovulation, or IVF (58, 74, 75). However, the theoretical, detrimental effects of testosterone on ovarian function and their potential reversibility have not been systematically investigated, and case reports provide proof of concept that mature oocytes, euploid embryos, and healthy live births can be achieved even when testosterone therapy is maintained during stimulation (76–79). Given that cessation of testosterone and the resultant increase in estradiol and/or resumption of menses are known to cause dysphoria in many transmasculine individuals, clinicians should have a frank discussion about what is and is not known about the potential effects of continuing testosterone during stimulation, so patients can make personalized, informed decisions (80). Unfortunately, conflicting findings have been reported in the limited literature and are limited to ex vivo studies on testosterone-exposed ovaries. Positive findings include normal folliculogenesis in response to follicle-stimulating hormone stimulation, normal cortical follicle distribution, and normal meiotic spindles in oocytes. More concerning findings include abnormal morphology and increased DNA damage, as well as poorer in vitro maturation outcomes in testosterone-exposed oocytes compared with donor (81– 83). More studies are also needed on the possible impact of pubertal blockers (84, 85). One additional consideration for younger populations is that the risk of aneuploidy in oocytes follows a U-shaped curve over a lifetime, with higher rates seen in both younger and older populations (86). As such, the optimal duration of testosterone cessation, or whether cessation is necessary at all, to ensure successful ovarian stimulation has not been determined. In this setting of inadequate data, the patient’s lived experience on and off testosterone therapy must be weighed with the potential for impaired ART outcomes.

Once ovarian stimulation has commenced, concomitant aromatase inhibitor administration has been suggested as a strategy to minimize peak estradiol (E2) levels and reduce associated dysphoria (73, 87). A similar strategy has been successfully employed in patients diagnosed with hormonally responsive breast cancer undergoing ovarian stimulation for fertility preservation (88, 89). Although not prospectively studied in TGD patients, available data suggests similar total oocyte yield and mature oocyte yield for ovarian stimulation cycles utilizing the nonsteroidal aromatase inhibitor, letrozole, in conjunction with gonadotropin stimulation compared with cycles utilizing gonadotropins alone (90).

ART Outcomes

The available literature evaluating ART outcomes in testosterone-treated TGD patients is largely limited to case reports and retrospective cohort studies. However, existing data suggest that TGD people undergoing ovarian stimulation after long-term androgen therapy have ovarian stimulation responses that are comparable to their cisgender counterparts, although all of these studies paused testosterone prior to stimulation (58, 74, 75). There is currently insufficient evidence on how long testosterone needs to be stopped or whether testosterone needs to be stopped at all prior to stimulation, if not planning to do an embryo transfer.

Ovarian Tissue Cryopreservation

Cryopreservation of surgically procured ovarian cortical tissue, known as ovarian tissue cryopreservation (OTC), allows for the preservation of thousands of ovarian follicles. OTC is an accepted option for fertility preservation and is no longer considered experimental (91). OTC is the only nonexperimental option for fertility preservation in prepubertal people AFAB and is now routinely utilized in adults prior to gonadotoxic therapy, with more than 180 live births reported in the literature (91, 92). Following OTC and orthotopic reimplantation, both medically assisted and unassisted pregnancies have been described (93–99). However, as mentioned above, there are limited and conflicting studies on the developmental capacity of in vitro matured oocytes originating from ovarian tissue obtained during gender-affirming surgery performed in the midst of testosterone treatment for GAHT.

Gender Dysphoria

TGD patients seeking fertility services may be at risk of recurrent or exacerbated gender dysphoria induced by ovarian stimulation, prestimulation testosterone cessation, or the changes in circulating steroid hormone levels associated with pregnancy. Increasing fatigue, vaginal secretions, menstruation, breast growth, or mastalgia occurring in the setting of frequent pelvic exams and transvaginal ultrasound monitoring may have transient or lasting effects on the mental health of TGD patients. Moreover, the predominantly cisgender and heteronormative environment present in obstetrics and gynecology clinics may also be uncomfortable for trans-identifying patients (100). Thus, offering a gender-neutral environment, facilitating access to mental health care services, and encouraging sensitivity training for front office staff, medical assistants, nurses, advanced practice providers, and physicians are strategies that may improve the experience of gender diverse patients in any healthcare setting (101). During ovarian stimulation specifically, clinicians may also consider employing transrectal or transabdominal ultrasonography to monitor patients who are uncomfortable with transvaginal ultrasound (102).

CONSIDERATIONS FOR TGD INDIVIDUALS AMAB

Modes of conception

TGD persons AMAB who have a penis, have testes, and engage in penetrative vaginal intercourse with a person with a uterus and ovaries may achieve unassisted conception. Alternatively, some people AMAB may not be comfortable with penetrative intercourse but are still able to ejaculate and produce a semen sample. In these cases, if they are partnered with someone with a uterus and ovaries, such couples may consider IUI. TGD people AMAB who are partnered with someone without ovaries or a uterus (or with someone not interested in using their reproductive organs for procreation) could pursue IVF using donor oocytes and a gestational carrier.

There is a paucity of literature on transitioning patients pursuing sperm cryopreservation. Semen quality in TGD individuals may be affected by the low frequency of masturbation, gender-affirming hormone use, and behaviors that increase scrotal temperatures, such as keeping the genitals against the body with tight underwear and bringing the testicles into the inguinal canal (tucking). It should be noted that even before commencing gender-affirming hormone therapy, these individuals have been shown to have an increase in abnormal semen analyses. Because poor parameters prior to cryopreservation are associated with further exacerbation, patients should be counseled on decreased semen quality compared with the general population. Anecdotally, many patients do not return to use cryopreserved specimens, and depending on the reproductive organ inventory of their partner, expensive treatments (e.g., use of a gestational carrier) may be necessary, including donor egg and gestational carrier. Sperm banks may offer discounted programs for transitioning patients that allow the waiving of certain requirements and can be completed later at the discretion of the medical director. Long-term storage may be more affordable by transferring cryopreserved material to another facility.

Production problems, patient preference, and/or risk of exacerbation of gender dysphoria may preclude the use of masturbation to provide a sample. Referral to reproductive urology for consideration for alternative techniques, including but not limited to electroejaculation and testicular sperm aspiration/extraction, is often warranted. Although limited, studies investigating gender affirming hormone therapy’s impact on spermatogenesis have demonstrated that semen analyses may improve after discontinuation of treatment (58). Further, orchiectomy studies have shown that germ cells are present in 80% of patients, with sperm present in ∼40% of cases (103, 104). Duration of hormone therapy did not appear to affect the degree of preservation of germ cells or spermatogenesis (103, 104). Follow-up studies on fertility in these instances have not been reported.

OTHER CONSIDERATIONS

A qualitative report on lesbian couples demonstrates the accompanying trauma from lack of control and experiencing miscarriage in the setting of LGBTQ+ family building (105). Additionally, a recent systematic review discussed how fathers face different challenges, as well as a lack of recognition for their own grief and unique needs, while highlighting the need for increased access to support services specifically for men (106). Related research on lesbians has described discrepancies in the experience of nonbirth mothers, including feelings of vulnerability, high stress, and a ‘‘hands-off attitude’’ compared with the birth mother, which may similarly apply to single as well as both fathers in a couple (107). When considering gay individuals pursuing treatment, a similar extrapolation may be made from the experiences of heterosexual fathers who describe feeling unequal, outnumbered, helpless, and distressed (17, 108, 109).

These issues are reported among nonbirthing mothers and heterosexual fathers, as we suspect they may be further exacerbated in other LGBTQ+ subgroups, such as gay men utilizing a gestational carrier, as neither are birthing or breastfeeding parents, and even when viewed as fathers, it can be through the traditional lens of being less emotional and less involved (17). Further, the LGBTQ+ population may need additional education on aspects of the reproductive system and delivery process, is susceptible to role confusion (e.g., one genetically related intended parent but both are the parents to a baby delivered by GC), and has described a perceived loss of control in the pregnancy and delivery process (17, 110).

Alternative approaches to LGBTQ+ family building

Traditionally, the LGBTQ+ community was restricted to foster care, adoption, and/or co-parenting (arrangements to conceive and raise child(ren) together without being in an intimate relationship) (111). With the advent of assisted reproductive technology (ART) treatment in the late 1970s, the chosen family is now extended to LGBTQ+ individuals having genetic children of their own; however, clinicians should be aware of these other options (112). Other arrangements may include, but are not limited to, non-traditional family structures, sperm donor co-parenting, even though the donor is not an intimate partner, and polyamorous relationships. Clinicians should be prepared to offer non-judgmental counseling and guidance.

Artificial gametogenesis

Patients may inquire about the ability to achieve genetic relation from both parents, therefore, warranting clinicians to become familiar with the concept of artificial gametes, including in vitro gametogenesis (reprogramming somatic cells to generate gametes) and stem cell-derived gametes (gamete derivation from progenitors such as germ-line stem cells, embryonic stem cells, or induced pluripotent stem cells). Scientific and ethical obstacles of clinical application notwithstanding, patients should not be made to feel that they have asked about something ‘‘unnatural’’, but rather counseled on the unavailability of these services and the unknown sequelae related to childhood development due to increased genetic manipulation, as well as potentially altered epigenetic imprinting (113).

COMMENT ON LANGUAGE

Throughout this document, we have used sexual and gender identity classifications to make information easy to find, to be concise, and to reflect the original terminology used by cited studies. The authors acknowledge that treatment options are largely independent of these identities and are primarily determined by the reproductive organ inventory of a patient and, when relevant, of their partner(s). We also recognize that the focus on couples and/or single parents by choice in prior research does not reflect the full diversity of relationship structures that present for family building.

Acknowledgments

This report was developed under the direction of the Practice Committee of the American Society for Reproductive Medicine (ASRM) as a service to its members and other practicing clinicians. Although this document reflects appropriate management of a problem encountered in the practice of reproductive medicine, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of management may be appropriate, taking into account the needs of the individual patient, available resources, and institutional or clinical practice limitations. The Practice Committee and the Board of Directors of the American Society for Reproductive Medicine have approved this report. This document was reviewed by ASRM members, and their input was considered in the preparation of the final document. The following members of the ASRM Practice Committee participated in the development of this document: Clarisa Gracia, M.D., M.S.C.E.; Rebecca Flyckt, M.D.; Karl Hansen, M.D., Ph.D.; Micah Hill, D.O.; Tarun Jain, M.D.; Suleena Kalra, M.D., M.S.C.E.; Bruce Pier, M.D.; Denny Sakkas, Ph.D.; Anne Steiner, M.D., M.P.H.; Cigdem Tanrikut, M.D.; Belinda Yauger, M.D.; Torie C. Plowden, M.D., M.P.H.; Ryan Smith, M.D.; Mark Trolice, M.D., M.B.A.; Suneeta Senapati, M.D.; Robert Brannigan, M.D.; Paula Amato, MD; Amy Sparks, Ph.D., H.C.L.D; Jared Robins, M.D.; Chevis N Shannon, Dr.Ph., M.B.A., M.P.H.; and Madeline Brooks, M.B.A., M.P.H. The Practice Committee acknowledges the special contributions of Micah Hill, D.O.; Molly Moravek, M.D.; Brent Monseur, M.D., Sc.M.; Tracy Harrison, M.D.; Amanda Adeleye, M.D.; Liam Kali, L.M.; Mark Leondires, M.D.; and Kim Bergman, Ph.D, in the preparation of this document. All Committee members disclosed commercial and financial relationships with manufacturers or distributors of goods or services used to treat patients. Members of the Committee who were found to have conflicts of interest on the basis of the relationships disclosed did not participate in the discussion or development of the document.

REFERENCES

1. Monseur B, Lee JA, Qiu M, Liang A, Copperman AB, Leondires M. Pathways to fatherhood: clinical experiences with assisted reproductive technology in single and coupled intended fathers. F S Reports 2022; 3:317–23.
2. Practice Committee of the American Society for. Reproductive Medicine and Practice Committee of the Society for Assisted Reproductive Technology. Guidance regarding gamete and embryo donation. Fertil Steril 2021; 115:1395–410.
3. Practice Committee of the American Society for Reproductive Medicine. Recommendations for reducing the risk of viral transmission during fertility treatment with the use of autologous gametes: a committee opinion. Fertil Steril 2020;114:1158–64.
4. Practice Committee of the American Society for Reproductive Medicine. Definition of infertility: a committee opinion. Fertil Steril 2023;120:1170.
5. Gianella S, Scheffler K, Mehta SR, Little SJ, Freitas L, Morris SR, et al. Seminal shedding of CMV and HIV transmission among men who have sex with men. Int J Environ Res Public Health 2015;12:7585–92.
6. Gotuzzo E, Verdonck K. HTLV-1: clinical impact of a chronic infection. In: Institute of Medicine (US) Forum on Microbial Threats, Knobler SL, O’Connor S, Lemon SM, et al., editors. The infectious etiology of chronic diseases: defining the relationship, enhancing the research, and mitigating the effects: workshop summary. Washington, DC: National Academies Press (US); 2004. Available at: https://www.ncbi.nlm.nih.gov/books/ NBK83714/. Accessed June 3, 2026.
7. Van Leeuwen E, Repping S, Prins JM, Reiss P, Van Der Veen F. Assisted reproductive technologies to establish pregnancies in couples with an HIV-1-infected man. Neth J Med 2009;67:322–7.
8. Shover CL, Devost MA, Beymer MR, Gorbach PM, Flynn RP, Bolan RK. Using sexual orientation and gender identity to monitor disparities in hiv, sexually transmitted infections, and viral hepatitis. Am J Public Health 2018;108:S277–83.
9. Haupert ML, Gesselman AN, Moors AC, Fisher HE, Garcia JR. Prevalence of experiences with consensual nonmonogamous relationships: findings from two national samples of single Americans. J Sex Marital Ther 2017; 43:424–40.
10. Ethics Committee of the American Society for Reproductive Medicine. Human immunodeficiency virus and infertility treatment: an Ethics Committee opinion. Fertil Steril 2021;115:860–9.
11. Practice Committee of the American Society for Reproductive Medicine and Practice Committee of the Society for Assisted Reproductive Technology. Recommendations for practices using gestational carriers: a committee opinion. Fertil and Steril 2022;118:65–74.
12. Practice Committee and the Mental Health Professional Group of the American Society for Reproductive Medicine. Guidance on qualifications for fertility counselors: a committee opinion. Fertil Steril 2021;115: 1411–5.
13. American Psychological Association. APA RESOLUTION on Sexual Orientation, Gender Identity (SOGI), Parents and their Children:1–7. Available at: https://www.apa.org/pi/lgbt/resources/policy/sexual-orientation. Accessed June 3, 2026.
14. Ethics Committee of the American Society for Reproductive Medicine. Informing offspring of their conception by gamete or embryo donation: an Ethics Committee opinion. Fertil Steril 2018;109:601–5.
15. Ethics and Practice Committees of the American Society for Reproductive Medicine. Updated terminology for gamete and embryo donors: directed (identified) to replace "known" and nonidentified to replace "anonymous": a committee opinion. Fertil Steril 2022;118:75–8.
16. Hemalal S, Yee S, Ross L, Loutfy M, Librach CL. Important decision-making considerations for same-sex male couples (SSMC) and single men (SM) when pursuing assisted reproductive technologies (ART). Fertil Steril 2019;112:e61.
17. Logan R. Gay fatherhood in the NICU: supporting the "gayby" boom. Adv Neonatal Care 2020;20:286–93.
18. Ross LE, Tarasoff LA, Anderson S, Epstein R, Marvel S, Steele LS, et al. Sexual and gender minority peoples' recommendations for assisted human reproduction services. J Obstet Gynaecol Canada 2014;36:146–53.
19. Carpinello OJ, Jahandideh S, Yamasaki M, Hill MJ, Decherney AH, Stentz N, et al. Does ovarian stimulation benefit ovulatory women undergoing therapeutic donor insemination? Fertil Steril 2021;115:638–45.
20. Courtot AM, Pallier C, Testart J. [Viral transmission and medically assisted procreation: the Herpesviridae case]. Gynecol Obstet Fertil 2004;32:233–40.
21. Michou V, Liarmakopoulou S, Thomas D, Tsimaratou K, Makarounis K, Constantoulakis P, et al. Herpes virus infected spermatozoa following density gradient centrifugation for IVF purposes. Andrologia 2012;44:174– 80.
22. Ripley M, Lanes A, Leveille M-C, Shmorgun D. Does ovarian reserve predict egg quality in unstimulated therapeutic donor insemination cycles? Fertil Steril 2015;103:1170–5.e2.
23. Gonzalez-Foruria I, Martinez F, Rodriguez-Purata J, Ballester M, Alonso-Mosquera V, Buxaderas R, et al. Can anti-Mullerian hormone predict success outcomes in donor sperm inseminations? Gynecol Endocrinol 2019; 35:40–3.
24. Hawkins Bressler L, Papworth B, Moustafa S, Chang A, Mersereau JE. Does empiric superovulation improve fecundity in healthy women undergoing therapeutic donor insemination without a male partner? Fertil Steril 2020;113:114–20.
25. Mu X, Wang H, Liu PJ, Shi JZ. The interval between insemination and ovulation predicts outcome after intrauterine insemination with donor sperm (IUI-D). Int J Gynecol Obstet 2022;156:341–8.
26. Blasco V, Prados N, Carranza F, Gonzalez-Ravina C, Pellicer A, Fernandez Sanchez M. Influence of follicle rupture and uterine contractions on intrauterine insemination outcome: a new predictive model. Fertil Steril 2014; 102:1034–40.
27. El Hachem H, Antaki R, Sylvestre C, Lapensee L, Legendre G, Bouet PE. Timing therapeutic donor inseminations in natural cycles: human chori
    onic gonadotrophin administration versus urinary LH monitoring. Reprod Biomed Online 2017;35:174–9.
28. Kyrou D, Kolibianakis EM, Fatemi HM, Grimbizis GF, Theodoridis TD, Camus M, et al. Spontaneous triggering of ovulation versus HCG administration in patients undergoing IUI: a prospective randomized study. Reprod Biomed Online 2012;25:278–83.
29. Owen M. Physiological signs of ovulation and fertility readily observable by women. Linacre Q 2013;80:17–23.
30. Direito A, Bailly S, Mariani A, Ecochard R. Relationships between the luteinizing hormone surge and other characteristics of the menstrual cycle in normally ovulating women. Fertil Steril 2013;99:279–85.e3.
31. Zhang D, Cai H, Xie J, Chen L, Zhang Z, Shi J. Cumulative live birth rates following intrauterine insemination using donor and husband sperm in different age groups: a cohort study of 10 415 insemination cycles. Int J Gynaecol Obstet 2024;167:142–53.
32. Bortoletto P, Willson S, Romanski PA, Davis OK, Rosenwaks Z. Reproductive outcomes of women aged 40 and older undergoing IVF with donor sperm. Hum Reprod 2021;36:229–35.
33. Carpinello OJ, Jacob MC, Nulsen J, Benadiva C. Utilization of fertility treatment and reproductive choices by lesbian couples. Fertil Steril 2016;106: 1709–13.e4.
34. Johal JK, Gardner RM, Vaughn SJ, Jaswa EG, Hedlin H, Aghajanova L. Pregnancy success rates for lesbian women undergoing intrauterine insemination. F S Reports 2021;2:275–81.
35. Kop PaL, Van Wely M, Nap A, Soufan AT, De Melker AA, Mol BWJ, et al. Intracervical insemination versus intrauterine insemination with cryopreserved donor sperm in the natural cycle: a randomized controlled trial. Hum Reprod 2022;37:1175–82.
36. Diego D, Medline A, Shandley LM, Kawwass JF, Hipp HS. Donor sperm recipients: fertility treatments, trends, and pregnancy outcomes. J Assist Reprod Genet 2022;39:2303–10.
37. Jellerette-Nolan T, Cooper AR, Doody KJ, Nichols JE, Park JK, Poe-Zeigler RL, et al. Real-world experience with intravaginal culture using INVOCELL: an alternative model for infertility treatment. F S Reports 2021;2: 9–15.
38. Doody KJ, Broome EJ, Doody KM. Comparing blastocyst quality and live birth rates of intravaginal culture using INVOcell to traditional in vitro incubation in a randomized open-label prospective controlled trial. J Assist Reprod Genet 2016;33:495–500.
39. Brandao P, Monseur B, Melo P, Goncalves-Henriques M, Ceschin N, Reis-Soares S, et al. Shared IVF among female couples: clinical outcomes of the Reception of Oocytes from the Partner (ROPA) method. Reprod Biomed Online 2023;47:103284.
40. Bodri D, Nair S, Gill A, Lamanna G, Rahmati M, Arian-Schad M, et al. Shared motherhood IVF: high delivery rates in a large study of treatments for lesbian couples using partner-donated eggs. Reprod Biomed Online 2018;36:130–6.
41. Practice Committee of the American Society for Reproductive Medicine. Performing the embryo transfer: a guideline. Fertil Steril 2017;107:882– 96.
42. Nunez A, Garcia D, Gimenez-Bonafe P, Vassena R, Rodriguez A. Reproductive outcomes in lesbian couples undergoing reception of oocytes from partner versus autologous in vitro fertilization/intracytoplasmic sperm injection. LGBT Health 2021;8:367–71.
43. Brandao P, Ceschin N, Cruz F, Sousa-Santos R, Reis-Soares S, Bellver J. Similar reproductive outcomes between lesbian-shared IVF (ROPA) and IVF with autologous oocytes. J Assist Reprod Genet 2022;39:2061–7.
44. Matorras R, Perez-Fernandez S, Hubel A, Ferrando M, Quintana F, Vendrell A, et al. Perinatal outcomes in lesbian couples employing shared motherhood IVF compared with those performing artificial insemination with donor sperm. Hum Reprod 2023;38:895–907.
45. Luo XF, Wu HL, Ji XR, Tang YL, Zhou WJ, Huang ZH, et al. Comparison of clinical outcomes, risks, and costs for 20,910 donor in vitro fertilization and 16,850 donor artificial insemination treatment cycles: a retrospective analysis in China. J Clin Med 2023;12:954.
46. Brandao P, Ceschin N. Lesbian shared IVF: the ROPA method: a systematic review. Porto Biomed J 2023;8:e202.
47. Practice Committee of the American Society for Reproductive Medicine in collaboration with the Society for Reproductive Endocrinology and Infertility. Optimizing natural fertility. Fertil Steril 2008;90:S1–6.
48. Practice Committee of the American Society for. Reproductive Medicine and the Practice Committee of the Society for Assisted Reproductive Technology. Recommendations for gamete and embryo donation: a committee opinion. Fertil Steril 2013;99:47–62.e1.
49. Ethics Committee of the American Society for Reproductive Medicine. Interests, obligations, and rights in gamete and embryo donation: an Ethics Committee opinion. Fertil Steril 2019;111:664–70.
50. Electronic Code of Federal Regulation (eCFR) [Internet]. 2023. PART 1271—HUMAN CELLS, TISSUES, AND CELLULAR AND TISSUE-BASED PRODUCTS. Available at: https://www.ecfr.gov/current/title-21/chapter-I/ subchapter-L/part-1271. Accessed June 3, 2026.
51. Jacobson H. A limited market: the recruitment of gay men as surrogacy clients by the infertility industry in the USA. Reprod Biomed Soc Online 2018; 7:14–23.
52. Practice Committee of the American Society for Reproductive Medicine. and the Practice Committee for the Society for Assisted Reproductive Technologies. Guidance on the limits to the number of embryos to transfer: a committee opinion. Fertil Steril 2021;116:651–4.
53. Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine treatment of gender-dysphoric/gender-
    incongruent persons: an endocrine society clinical practice guideline. Endocr Pract 2017;23:1437.
54. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, Decuypere G, Feldman J, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgend Health 2012;13:165–232.
55. Grant JM, Mottet L, Tanis JE, Harrison J, Herman J, Keisling M. National transgender discrimination survey, [United States], 2008-2009, Inter-university Consortium for Political and Social Research [distributor]; 2020. https://doi.org/10.3886/ICPSR37888.v1.
56. Mcfarland J, Craig W, Clarke NJ, Spratt DI. Serum testosterone concentrations remain stable between injections in patients receiving subcutaneous testosterone. J Endocr Soc 2017;1:1095–103.
57. Nakamura A, Watanabe M, Sugimoto M, Sako T, Mahmood S, Kaku H, et al. Dose-response analysis of testosterone replacement therapy in patients with female to male gender identity disorder. Endocrine J 2013; 60:275–81.
58. Adeleye AJ, Reid G, Kao CN, Mok-Lin E, Smith JF. Semen parameters among transgender women with a history of hormonal treatment. Urology 2019;124:136–41.
59. Rodriguez-Wallberg KA, H€aljestig J, Arver S, Johansson ALV, Lundberg FE.Sperm quality in transgender women before or after gender affirming hormone therapy—a prospective cohort study. Andrology 2021;9:1773–80.
60. De Nie I, Asseler J, Meißner A, Voorn-De Warem IaC, Kostelijk EH, Den Heijer M, et al. A cohort study on factors impairing semen quality in transgender women. Am J Obstet Gynecol 2022;226:e1–10.
61. Practice Committee of the American Society for Reproductive Medicine. Fertility evaluation of infertile women: a committee opinion. Fertil Steril 2021;116:1255–65.
62. Schlegel PN, Sigman M, Collura B, De Jonge CJ, Eisenberg ML, Lamb DJ, et al. Diagnosis and treatment of infertility in men: AUA/ASRM guideline part I. Fertil Steril 2021;115:54–61.
63. Ethics Committee of the American Society for Reproductive Medicine. Access to fertility services by transgender persons: an Ethics Committee opinion. Fertil Steril 2015;104:1111–5.
64. Cipres D, Seidman D, Cloniger C, Nova C, O'shea A, Obedin-Maliver J. Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco. Contraception 2017;95:18–9.
65. Moseson H, Zazanis N, Goldberg E, Fix L, Durden M, Stoeffler A, et al. The imperative for transgender and gender nonbinary inclusion. Obstet Gynecol 2020;135:1059–68.
66. Moseson H, Fix L, Hastings J, Stoeffler A, Lunn MR, Flentje A, et al. Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: results from a national, quantitative survey. Int J Transgend Health 2021;22:30–41.
67. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol 2014;124:1120–7.
68. Chen D, Simons L, Johnson EK, Lockart BA, Finlayson C. Fertility preservation for transgender adolescents. J Adolesc Health 2017;61:120–3.
69. James-Abra S, Tarasoff LA, Green D, Epstein R, Anderson S, Marvel S, et al. Trans people's experiences with assisted reproduction services: a qualitative study. Hum Reprod 2015;30:1365–74.
70. Moravek MB, Obedin-Maliver J. You miss 100% of the shots you don't take: time to push boundaries in fertility care of transgender people. Fertil Steril 2021;116:357–8.
71. Moravek MB, Kinnear HM, George J, Batchelor J, Shikanov A, Padmanabhan V, et al. Impact of exogenous testosterone on reproduction in transgender men. Endocrinology 2020;161:bqaa014.
72. Rogers C, Webberley M, Mateescu R, El Rakhawy Y, Daly-Gourdialsing A, Webberley H. A retrospective study of positive and negative determinants of gamete storage in transgender and gender-diverse patients. Int J Transgend Health 2021;22:167–78.
73. Martin CE, Lewis C, Omurtag K. Successful oocyte cryopreservation using letrozole as an adjunct to stimulation in a transgender adolescent after GnRH agonist suppression. Fertil Steril 2021;116:522–7.
74. Leung A, Sakkas D, Pang S, Thornton K, Resetkova N. Assisted reproductive technology outcomes in female-to-male transgender patients compared with cisgender patients: a new frontier in reproductive medicine. Fertil Steril 2019;112:858–65.
75. Amir H, Oren A, Klochendler Frishman E, Sapir O, Shufaro Y, Segev Becker A, et al. Oocyte retrieval outcomes among adolescent transgender males. J Assist Reprod Genet 2020;37:1737–44.
76. Greenwald P, Dubois B, Lekovich J, Pang JH, Safer J. Successful In vitro fertilization in a cisgender female carrier using oocytes retrieved from a transgender man maintained on testosterone. AACE Clin Case Rep 2022;8:19–21.
77. Stark BA, Mok-Lin E. Fertility preservation in transgender men without discontinuation of testosterone. F S Rep 2022;3:153–6.
78. Moravek MB, Dixon M, Pena SM, Obedin-Maliver J. Management of testosterone around ovarian stimulation in transmasculine patients: challenging common practices to meet patient needs—2 case reports. Hum Reprod 2023;38:482–8.
79. Gale J, Magee B, Forsyth-Greig A, Visram H, Jackson A. Oocyte cryopreservation in a transgender man on long-term testosterone therapy: a case report. F S Rep 2021;2:249–51.
80. Armuand G, Dhejne C, Olofsson JI, Rodriguez-Wallberg KA. Transgender men's experiences of fertility preservation: a qualitative study. Hum Reprod 2017;32:383–90.
81. Van Den Broecke R, Van Der Elst J, Liu J, Hovatta O, Dhont M. The female-to-male transsexual patient: a source of human ovarian cortical tissue for experimental use. Hum Reprod 2001;16:145–7.
82. Lierman S, Tolpe A, De Croo I, De Gheselle S, Defreyne J, Baetens M, et al. Low feasibility of in vitro matured oocytes originating from cumulus complexes found during ovarian tissue preparation at the moment of gender confirmation surgery and during testosterone treatment for fertility preservation in transgender men. Fertil Steril 2021;116:1068–76.
83. Bailie E, Maidarti M, Jack S, Hawthorn R, Watson N, Telfer E, et al. The ovaries of transgender men indicate effects of high dose testosterone on the primordial and early growing follicle pool. Reprod Fertil 2023;4:e220102.
84. Insogna IG, Ginsburg E, Srouji S. Fertility preservation for adolescent transgender male patients: a case series. J Adolesc Health 2020;66:750–3.
85. Rothenberg SS, Witchel SF, Menke MN. Oocyte cryopreservation in a transgender male adolescent. N Engl J Med 2019;380:886–7.
86. Gruhn JR, Zielinska AP, Shukla V, Blanshard R, Capalbo A, Cimadomo D, et al. Chromosome errors in human eggs shape natural fertility over reproductive life span. Science 2019;365:1466–9.
87. Baram S, Myers SA, Yee S, Librach CL. Fertility preservation for transgender adolescents and young adults: a systematic review. Hum Reprod Update 2019;25:694–716.
88. Kim J, Turan V, Oktay K. Long-term safety of letrozole and gonadotropin stimulation for fertility preservation in women with breast cancer. J Clin Endocrinol Metab 2016;101:1364–71.
89. Oktay K. Further evidence on the safety and success of ovarian stimulation with letrozole and tamoxifen in breast cancer patients undergoing in vitro fertilization to cryopreserve their embryos for fertility preservation. J Clin Oncol 2005;23:3858–9.
90. Letourneau J, Juarez-Hernandez F, Wald K, Ribeiro S, Wang A, Mcculloch CE, et al. Concomitant tamoxifen or letrozole for optimal oocyte yield during fertility preservation for breast cancer: the TAmoxifen or Letrozole in Estrogen Sensitive tumors (TALES) randomized clinical trial. J Assist Reprod Gen 2021;38:2455–63.
91. Practice Committee of the American Society for Reproductive Medicine. Fertility preservation in patients undergoing gonadotoxic therapy or gonadectomy: a committee opinion. Fertil Steril 2019;112:1022–33.
92. Sheshpari S, Shahnazi M, Mobarak H, Ahmadian S, Bedate AM, Nariman-Saleh-Fam Z, et al. Ovarian function and reproductive outcome after ovarian tissue transplantation: a systematic review. J Transl Med 2019;17:396.
93. Silber SJ, Lenahan KM, Levine DJ, Pineda JA, Gorman KS, Friez MJ, et al. Ovarian transplantation between monozygotic twins discordant for premature ovarian failure. New Engl J Med 2005;353:58–63.
94. Silber SJ, Derosa M, Goldsmith S, Fan Y, Castleman L, Melnick J. Cryopreservation and transplantation of ovarian tissue: results from one center in the USA. J Assist Reprod Gen 2018;35:2205–13.
95. Donnez J, Dolmans M-M, Pellicer A, Diaz-Garcia C, Sanchez Serrano M, Schmidt KT, et al. Restoration of ovarian activity and pregnancy after transplantation of cryopreserved ovarian tissue: a review of 60 cases of reimplantation. Fertil Steril 2013;99:1503–13.
96. Anderson RA, Wallace WHB, Telfer EE. Ovarian tissue cryopreservation for fertility preservation: clinical and research perspectives. Hum Reprod Open 2017;2017:hox001.
97. Roux C, Amiot C, Agnani G, Aubard Y, Rohrlich P-S, Piver P. Live birth after ovarian tissue autograft in a patient with sickle cell disease treated by allogeneic bone marrow transplantation. Fertil Steril 2010;93:2413.e15–9.
98. Dittrich R, Hackl J, Lotz L, Hoffmann I, Beckmann MW. Pregnancies and live births after 20 transplantations of cryopreserved ovarian tissue in a single center. Fertil Steril 2015;103:462–8.
99. Donnez J, Dolmans M-M. Fertility preservation in women. New Engl J Med 2017;377:1657–65.
100. Kirubarajan A, Patel P, Leung S, Park B, Sierra S. Cultural competence in fertility care for lesbian, gay, bisexual, transgender, and queer people: a systematic review of patient and provider perspectives. Fertil Steril 2021; 115:1294–301.
101. Practice Committee of the American Society for Reproductive Medicine. Inclusive language and environment to welcome lesbian, gay, bisexual, transgender, queer, questioning, intersex, and asexual+ patients. Fertil Steril 2024;121:954–60.
102. Barrett F, Shaw J, Blakemore JK, Fino ME. Fertility preservation for adolescent and young adult transmen: a case series and insights on oocyte cryopreservation. Front Endocrinol (Lausanne) 2022;13:873508.
103. Jindarak S, Nilprapha K, Atikankul T, Angspatt A, Pungrasmi P, Iamphongsai S, et al. Spermatogenesis abnormalities following hormonal therapy in transwomen. BioMed Res Int 2018;2018:1–5.
104. Jiang DD, Swenson E, Mason M, Turner KR, Dugi DD, Hedges JC, et al. Effects of estrogen on spermatogenesis in transgender women. Urology 2019;132:117–22.
105. Wojnar D. Miscarriage experiences of lesbian couples. J Midwifery Womens Health 2007;52:479–85.
106. Obst KL, Due C, Oxlad M, Middleton P. Men's grief following pregnancy loss and neonatal loss: a systematic review and emerging theoretical model. BMC Pregnancy Childbirth 2020;20:11.
107. Mckelvey MM. The other mother: a narrative analysis of the postpartum experiences of nonbirth lesbian mothers. Adv Nursing Sci 2014;37:101– 16.
108. Deeney K, Lohan M, Spence D, Parkes J. Experiences of fathering a baby admitted to neonatal intensive care: a critical gender analysis. Soc Sci Med 2012;75:1106–13.
109. Kelly O'brien C, Leahy Warren P. Fathers' perceptions of neonatal nursing support. J Neonatal Nurs 2014;20:236–41.
110. Blake L, Carone N, Slutsky J, Raffanello E, Ehrhardt AA, Golombok S. Gay father surrogacy families: relationships with surrogates and egg donors and parental disclosure of children's origins. Fertil Steril 2016;106:1503–9.
111. Rivers DW. Radical relations : lesbian mothers, gay fathers, and their children in the United States since World War II. North Carolina: The University of North Carolina Press; 2013. Available at: https://uncpress.org/ 9781469626451/radical-relations/. Accessed June 3, 2026.
112. Rabun C, Oswald RF. Upholding and expanding the normal family: future fatherhood through the eyes of gay male emerging adults. Fathering 2009;7:269–85.
113. Hendriks S, Dondorp W, De Wert G, Hamer G, Repping S, Dancet EA. Potential consequences of clinical application of artificial gametes: a systematic review of stakeholder views. Hum Reprod Update 2015;21:297–309.