(Almost) Everything You Need to Know About T and Fertility

Many people with uteruses and ovaries who are considering or taking exogenous testosteroneexternal link, opens in a new tab (that’s the medical term for testosterone that a body does not produce on its own), often for gender⁠ (gender: Characteristics that are seen or presented as distinguishing between male and female in a society. Gender may or may not include assigned or chosen: social roles, feelings, behaviors and/or presentation or appearance.) -affirming care, have questions about fertility. Some people worry about getting pregnant while on testosterone while others think about the desire⁠ (desire: A feeling of wanting something. In the context of sex or sexuality, desire can be a feeling of a physical and psychological want for any kind of sex or way of being sexual.) to have children in the future, whether by becoming pregnant or working with a pregnancy surrogate. Plenty of people just want to know about any possible changes to fertility to make informed decisions about taking T, like they might with any medication.

This is a relatively new area of medicine and researchers are still gathering information about testosterone’s effect on fertility, but I want to give you the lowdown on what we do know. 

Of note: Many adults⁠ (adults: People whose age in years exceeds the legal age of majority, people considered to be adults by law, or people who a culture or individual considers to have reached an adult stage of life.) have strong opinions about the use of hormones⁠ (hormones: Chemicals – via our endocrine system – that send messages across our bodies and brains. They both naturally exist and can also be made in a lab.) , especially for gender-affirming care, in youth that are more about their personal hangups and beliefs than they are about your health. They often cite fears about fertility as a major concern, whether you are taking testosterone to explore or get more comfortable in your body or are using it for another reason, such as a medical condition. I know some people also take testosterone for sports performance; in most countries, this may disqualify you from competition or could be illegal, but you should still be able to make decisions about if, when, and how you use testosterone with access to as much information as possible. 

Adults like to claim youth aren’t capable of making well-informed decisions for themselves, and may later regret healthcare that could affect fertility. You may have heard statements like “you’re too young for such a big choice,” or “you may not care about children now, but you could in the future.” At Scarleteen, we don’t believe we know what’s best for you better than you do. This is something you know for yourself, and the more information you have about the risks and benefits of anything, the more empowered you are. If you have anyone in your life who’s pressuring you around fertility or anything else related to taking testosterone, you might want to share this article with them, both to show them that you are thinking about this and to provide them with information they may not know about.

Just because you are the person best equipped to know best about yourself doesn’t mean you don’t need help sometimes figuring out⁠ (out: Short for ‘out of the closet’. When someone’s LGBTQ+ identity is known to other people.) what (and who) that is. We all need help with that sometimes, whatever our age. If you need help figuring out things like this for yourself, we’re always happy to do what we can to pitch in.

Every body is different, and so is every clinic or healthcare provider⁠ (healthcare provider: A qualified person to provide sound physical and/or mental healthcare, such as a doctor, nurse, clinician, counselor, medical assistant, midwife or other healthcare professional.) . Before starting testosterone, healthcare providers should discuss the risks and benefits with patients, including concerns related to fertility and why you want to take testosterone. You should feel comfortable asking as many questions as you need to make decisions about hormones before you begin. (If you are self-managing for any reason, please do try to find a provider who can support you in case issues arise!) And you should be aware that you can work with your provider to tweak your dosage, take breaks, or stop altogether if you don’t like the results you’re getting, can’t tolerate the side effects, or feel like you don’t need T anymore.

Here’s the tl;dr: If you had the capacity to become pregnant before using T, or have not experienced menopause, know that it is always possible to become pregnant while taking testosterone, and it should never be used as a form of birth control⁠ (birth control: Any number of methods people use to intentionally prevent unwanted pregnancy, including the condom, the cervical barrier, the implant, the patch, the pill, the rhythm method, the ring, the shot, the IUD, spermicide and withdrawal.) , because it is not intended to act as birth control. Additionally, there are some concerns about the effects of testosterone on developing fetuses, and most sources recommend against the use of testosterone in pregnancy or for people who are trying to get pregnant. Testosterone can also have effects on your ability to get pregnant if you want to become pregnant, whether now or in the future.

If you are engaging in sex that could result in pregnancy and you do not want to become pregnant, you should use a method, medication, or other tool designed for use as birth control and discuss options with your doctor. Condoms are a highly effective form of birth control that do not require a prescription from a physician and also protect you from sexually-transmitted infections. But there’s so much more! You can review all your options at Birth Control Bingo.

If you’re taking T and you’re worried you might be pregnant right now, you may want to review our Pregnancy Panic Companion and THEN come back to this article. It’s not going anywhere, I promise!

The Basics of Testosterone and Fertility

If You Haven’t Gone Through Puberty

If you haven’t gone through puberty yet, you cannot get pregnant, but taking hormones before puberty may affect your ability to get pregnant in the future. If you are considering hormones as part of gender-affirming care or you are taking them for other reasons, here’s the scoop.

The first option for youth pre-puberty is gonadotropin-releasing hormone (GnRH) agonists, also called puberty blockers, which effectively put a pause on puberty, telling the body to stop making hormones such as testosterone in people with testicles, and estrogen⁠ (estrogen: A steroid hormone found in the bodies of all people, produced in the ovaries and the adrenal glands.It is involved in puberty, menstruation, pregnancy, mood, bone health, and other things across the body and lifespan .) in people with ovaries. Blockers are reversible and if patients stop taking them, their bodies will pick up where they left off. However, some studies have found that because blockers put the development of germ cells (that’s your ovaries!) on hold, patients may experience disruptions to fertility after stopping blockersexternal link, opens in a new tab. This potential side effect is still under investigation: We don’t have enough data yet to draw definitive conclusions.

The second is to start taking testosterone immediately, although this option is not available to all youth for a variety of reasons; sometimes it is outright banned and sometimes it is not provided by a given clinic, for example. If you opt to do this, you will not experience ovarian development like you would with estrogen and other sex hormones your body would have produced. Because your ovaries won’t get a chance to develop, and will not develop follicles (the tiny sacs in the ovary that swell during ovulation, and then release an egg) you will not be able to get pregnant on your own ever, even if you go off testosterone in the future.

If you’re thinking ahead to having kids, your fertility preservation options — basically, banking potential for the future — are extremely limited if you start T before puberty or are concerned about the effects of blockers on your fertility. In fact, there’s only one current option: Ovarian tissue cryopreservationexternal link, opens in a new tab, in which doctors remove some ovarian tissue and put it on ice. Later, it can be thawed, encouraged to develop, and autotransplanted back into your body. It’s also possible to use in-vitro (in a lab, not your body) techniques to grow and mature the follicles and extract eggs which can be fertilized with donor sperm⁠ (sperm: Reproductive cells of people with penises which can fertilize an ovum and create pregnancy.) and implanted in the original patient or a surrogate.

Some issues to be aware of with this option:

• It’s very expensive and usually not covered by insurance or national health
• It is not offered by very many clinics and you will need to see a specialist
• If you are under the age of majority, you may not be able to access this care at all whether because of legal restrictions or the need for parental consent⁠ (consent: To freely and actively agree to do a specific thing with someone else with all the information about what that thing is, and the right to change your mind.)
• There’s very limited evidence about the effectiveness⁠ (effectiveness: How well something works.) of this option, and you should consider it pretty experimental. When this option fails, it means that you will not have viable oocytes (eggs), whether you want to become pregnant yourself or partner⁠ (partner: In a sexual context, a person with whom someone is having some kind of sex. The term “partner” can be used for all kinds of relationships, not just serious ones. “Partner” can also mean the person someone is with in a romantic or familial partnership.) with a gestational surrogate.

Bottom line: If you think that you want to pass your genes on to your children, you may not want to take puberty blockers or testosterone before puberty.

If You Are Taking Testosterone After the Start of Puberty

If you start taking testosterone after you have started puberty, you may stop ovulating and menstruating; for some, these are considered desirable side effects. However, people can and do get pregnant while taking testosterone, even with irregular periods, especially if they have unstable access to hormones or take testosterone intermittently; within three to six months of stopping testosterone therapy, around 80 percent of people reported that they had started menstruating again. Notably, a study found that one-third of pregnancies after stopping T were unplannedexternal link, opens in a new tab!

The dose of T you’re taking may have an effect, but again, it varies depending on your body. From microdosing to taking doses more towards the top end of the range to self-managing hormones, there can be a lot going on in your body. It’s a good idea to at minimum get regular labs, if you can, to check on your testosterone levels and other markers that may have an impact on your overall health, such as cholesterol and A1C. This is also another instance where we need more scientific evidence on the interactions of T and fertility.

The evidence on long-term testosterone use and pregnancy is still unclear because this is such a new area of medicine, but a lot of studies suggest that people can and do get pregnant if they stop taking testosterone, even after years on the hormoneexternal link, opens in a new tab. Some people, however, experience permanent changes to their ovariesexternal link, opens in a new tab that make it difficult, and sometimes impossible, to get pregnant without medical assistance and, sometimes, a donor egg.

Bottom line: The effects of testosterone on your ovaries and ability to get pregnant can depend on consistent access, dosage, and your own body.

Testosterone and Pregnancy

Testosterone is considered a teratogenexternal link, opens in a new tab, which means it can cause birth defects, some of which may be lethal. For this reason, patients taking testosterone are strongly advised to use birth control. If they do become pregnant, they should seek treatment immediately to decide whether they want to continue the pregnancy and discuss the risks with their doctor. If you have other medical conditions that could make pregnancy unsafe or tricky for you, discuss those with your doctor as well. If you are self-managing, it’s also important to see a doctor, and you may want to seek recommendations from your community about providers who will be respectful with you, ideally those who specialize in harm reduction (a field that acknowledges people may self-manage some medications, but still deserve access to health care).

This may seem obvious, but worth noting that if you have received surgeries around your genitals⁠ (genitals: Body parts that are generally, culturally, scientifically or personally considered to be external sexual or reproductive organs.) , specifically removal of your uterus⁠ (uterus: An internal, muscular reproductive organ in the pelvis. During pregnancy, this is where a fetus will develop. The lining of a person’s uterus is also the thing that sheds every menstrual cycle in what we call a period.) and ovaries, you will not be able to get pregnant, whether or not you are on T. If your ovaries are removed but your uterus is intact, you cannot get pregnant without using a medical intervention such as IVF.

I Don’t Want to Get Pregnant!

We have a specific list of things that best prevent pregnancy to consider while you’re thinking about pregnancy risks.

If you are engaging in the kind of sex that can result in pregnancy, use birth control! Our Birth Control Bingo series reviews your options, including sterilization whether via tubal ligation (“having your tubes tied”) or hysterectomy (removal of your uterus) if you’d like to pursue those options, although they are rarely offered to people under 18.

There are lots of tools you can use to track ovulation and your potential ability to get pregnant that might help you understand your fertility. These include charting⁠ (charting: Methods for keeping track of fertility and/or menstrual cycles. ) your body’s rhythms on your own or using an app to assist you, but because testosterone can cause irregular periods or stop them altogether, these tools can be tricky to use and you should consider them an addition to your pregnancy prevention routine or a way to learn more about your body, not a replacement for birth control.

Incidentally, if you are trans and you want to update your identification, be aware that some countries require trans people to provide proof of sterilizationexternal link, opens in a new tab before they are allowed to change their gender markers on official documents. These policies are usually not, however, out of a concern about the risks of testosterone in pregnancy: They are rooted in the transphobic belief that trans people should not be allowed to have childrenexternal link, opens in a new tab.

I Don’t Want to Get Pregnant Right Now, or I’m Not Sure If I Want to Get Pregnant in the Future

Thinking about pregnancy at some point in your life? Want to know your options? There are two paths to follow.

Fertility Preservation

You might want to consider some fertility preservation options before you start hormones if you think you want to have kids in the future or you want to keep your options open. It’s important to know that this requires care in a specialty clinic, it can be pretty invasive and grueling, and it’s usually expensive and not covered by insurance or national health, if it’s offered to you at all.

In addition to ovarian tissue cryopreservation, you have two options after you have gone through puberty and your ovaries have fully developed: Oocyte cryopreservation (freezing your eggs) or embryo⁠ (embryo: During a pregnancy, the term for the developing cells of an organism until around eight-nine weeks after an ovum was fertilized. After this time, the organism would then be called a fetus.) cryopreservation (freezing eggs that have been fertilized to create an embryo). With both of these options, in addition to the procedures themselves, you should think about long-term costs, including those associated with storage and procedures to allow you or a surrogate to get pregnant and provide support in pregnancy on the other side when you’re ready.

Freezing eggs is a solo activity and it’s exactly what it sounds like: You will take some medications to stimulate your ovaries to develop follicles and prepare to release eggs, and your doctor will harvest some eggs that you can freeze and thaw later when you want to use them. When you thaw them, the eggs will need to be fertilized via donor sperm. This sperm can come from a sperm bank or a known donor, such as a partner or friend. Once your eggs are fertilized and have started developing into embryos, they can be implanted in your uterus or that of a gestational surrogate. This is known as in-vitro fertilization (IVF). Doctors typically create several embryos in case something goes wrong.

Embryo cryopreservation requires a sperm donation to fertilize the egg after it has been harvested. The lab will freeze the embryo (usually more than one so you have some backups) and when you’re ready, a doctor will thaw an embryo and perform a procedure to implant it.

In both cases, you will be strongly advised to stop using testosterone prior to receiving treatment to prepare for implantation⁠ (implantation: When fertilized ovum attach to the lining of the uterus during the process of human reproduction.) and pregnancy due to concerns about its effect on the success of IVF and the fetus⁠ (fetus: In humans, the stage of prenatal development after an embryo, usually from about the eighth-ninth week after fertilization.) ’ development; if you do not want to stop testosterone, your doctor may warn that it is against medical advice or decline to treat you. If you are considering self-managing hormones and not discussing this with your provider to get around this, please be advised that this can be a very high-risk choice for you and a fetus.

Pregnancy and Assisted Reproduction Without Fertility Preservation

If you opt against fertility preservation, or it wasn’t an option for you at the time, you can potentially still get pregnant in the future. As noted above, it’s possible to get pregnant while taking T, and if you stop for three to six months, your chances of getting pregnant get much higher. For people who want to get pregnant, doctors usually recommend waiting at least three months before trying, although as discussed above, some people have opted to try for pregnancy while still on testosterone, or after stopping for just a few weeks, as this case study demonstratesexternal link, opens in a new tab.

Some people conceive on their own without any assistance.

Others will need some form of assisted reproduction, if they can’t conceive on their own, want to use a donor egg, or want to work with a surrogate. This can include IVF, or another method, interuterine insemination (IUI), in which a doctor introduces sperm to the uterus after ovulation. (Sometimes crudely known as the “turkey baster method.”) For these methods, the patient will need to stop taking T and take a series of medications to trigger⁠ (trigger: In the context of behavior, a trigger is an experience that triggers a traumatic memory in someone who has experienced trauma.) ovulation and prepare their bodies for egg retrieval and/or pregnancy.

Research has found that, generally speaking, people who have stopped taking testosterone respond well to ovarian stimulation and have success rates with assisted reproduction similar to those of cis peopleexternal link, opens in a new tab. Most of this research is about trans people, since they are a large population of people with uteruses and/or ovaries who take testosterone.

For Trans and Gender Nonconforming People: Dysphoria and Fertility

The big drawback to stopping T for trans and otherwise gender nonconforming⁠ (gender nonconforming: People who do not adhere to or who protest cultural rules or norms about dress, behaviors or activities for people based on their sex.) people who want to get pregnant or prepare to harvest an egg is probably pretty obvious: You may experience some reversal of the gender-affirming effects that you experienced. Some people find that stopping hormone therapy can increase feelings of dysphoria, especially if they get pregnant. Others have reported that being a “seahorse dadexternal link, opens in a new tab” has actually been very gender-affirming for them!

Changes to your body aren’t just about stopping T. Pregnancy and medications you may take if you need help getting pregnant ramp up all kinds of hormones and feelings that can cause symptoms that may feel very activating for you, such as breast⁠ (breast: Glandular tissue, fat, connective tissue and skin on the chest.) growth and tenderness—including if you’ve had top surgery, because some breast tissue remains behind. (Incidentally, it can be possible to chestfeed your baby after top surgeryexternal link, opens in a new tab, if that’s something you’re interested in, and if a partner wants to produce milk, there are options for induced lactation to help them do that. If you think you might want to chestfeed, discuss this with your surgeon while you plan for top surgery.)

Unfortunately, it’s hard to tell where on the spectrum you fall until you’re experiencing dysphoria, and it may be a year or more before you can safely start taking T again if you decide to continue trying to get pregnant or carrying a pregnancy. That can feel like an eternity, especially when surrounded by people who assure you that it’s no big deal and you won’t even remember this period⁠ (period: The fluid – or flow – which contains blood, from the shedding of the uterine lining usually at the end of each menstrual cycle. Sometimes periods may be less fluid and more globby; this is the state that is often mistaken for blood clotting.) in your life once you become a parent.

Because dysphoria is definitely a risk, seek companionship and support in community. Other people have gone on the same journey and may have wisdom, or just openness to listening, that could help you navigate these feelings. A therapist who works with trans and gender nonconforming people, especially if they are experienced with working with pregnant people, can also help you explore your feelings and find ways to manage them.

If at any point along your fertility and pregnancy journey you feel like you can’t or don’t want to continue, remember that you have the ultimate control over your body. If you’re pregnant and don’t want to be, abortion⁠ (abortion: A procedure to intentionally end a pregnancy before a birth. Miscarriage is also sometimes called “spontaneous abortion,” even though it is usually not intended.) services can be an option. Depending on where you live, your access to abortion may, however, be entirely illegal or decline the further into pregnancy you are. That’s an important consideration as you check in with yourself about how you are feeling; it’s a good idea to research and understand abortion law where you are, and to think ahead about what you will do if you no longer want to be pregnant or it is not safe to continue your pregnancy.

Finding Affirming Providers for Fertility Care

For people who use testosterone for gender-affirming care or to feel more comfortable in their bodies for any reason, it’s really important to find a fertility provider, as well as an OB-GYN, who is familiar with patients like them and actively wants to care for them. (Fertility providers help you get pregnant, and OB-GYNs care for you in pregnancy and delivery.) If you’re using testosterone for other reasons, it’s equally important to find a provider who has experience working with patients like you, because your medical needs need to be considered when helping you on your fertility journey. You may also find that people assume you take testosterone for gender-affirming care, which could mean that you face transphobia⁠ (transphobia: Prejudice against transgender individuals. Transphobia may also include prejudice against any kind of gender nonconformity or gender nonconforming people.) —even if you aren’t trans!

If you’re trans or otherwise gender nonconforming, you already know we live in a transphobic world, and many trans and gender nonconforming people — a majority, in fact — report experiencing transphobia at the doctor’s office, from microaggressions to denial of care to interacting with providers who don’t understand their health, even if they are doing their best. This is a particularly acute problem for youth, who experience adultism and transphobia when they seek care, especially if they are under the age of majority and need parental approval or support. This comes up in fertility care too, including discussions about future fertility.

For whatever reason that you’ve been taking testosterone and you’re thinking about pregnancy, our Dealing with Doctors article provides some information that can help you navigate the health care system, including providers, insurance, national health, and other corners of the medical world. At the very least, seek recommendations through your networks, on forums, and via review sites to identify a provider you like, and use your first appointment to test the waters and see if they area good fit for you. If you don’t like the vibe, it’s a good idea to explore other options, though you may be constrained by your insurance (or lack thereof) or lengthy referral times for care. Explicitly ask your provider about their experience working with people who have been taking testosterone and thoroughly review your medical history to make sure you and your provider are on the same page about your health, safety, and needs.

Because queer⁠ (queer: In the context of sexuality, a broad term for sexual orientation that can describe any number of orientations which are not heterosexual. People who identify as queer may be bisexual or pansexual, gay or lesbian, questioning, asexual or more.) -friendly fertility clinics and OB/GYNs tend to have more experience with people taking T who are interested in pregnancy, they can be a good place to start when looking for a fertility provider as well as a medical team to support you through pregnancy, regardless of your gender and/or sexuality. Many queer communities share recommendations, and you can also take a look at provider websites to learn about the services they provide. Watch for indicators such as inclusive language as well as imagery: Do you see a pregnant man on their landing page? Do they refer to “female bodies,” implying that only cis women can get pregnant? What do providers say in their biographies? If the facility is associated with an academic medical center, consider checking out a provider’s scientific publications to learn more about the focus of their work and how they think about their patients.

You should also think about where and how you want to give birth. There are a variety of options available to birthing people, including queer and trans friendly providers and clinics, who again tend to be more supportive because of their experience with trans patients taking testosterone. Explore those options well in advance as well as thinking about whether you are comfortable delivering vaginally or would prefer a planned c-section, or want to work with a provider who will support either option. It’s also worth thinking about what will happen in an obstetrical emergency. If the nearest emergency medical facility is hostile to trans people, that could endanger you or your baby because they will make assumptions about the history of testosterone use in your medical record. Some people opt to temporarily relocate during pregnancy, especially if they are close to their due dates, to have more control over where they might be taken and how they will be treated if there’s an emergency, or if they live in an area with restrictive abortion access and want to make sure they have access to termination or miscarriage⁠ (miscarriage: When a pregnancy ends before birth all by itself, often without anyone having done anything to make that happen.) care if something goes wrong in pregnancy.

Make sure you have conversations with your partner and/or loved ones about how you want them to handle an emergency, and also write an advance directive (this form may go by a variety of names, depending on where you live) that gives them a healthcare power of attorney and clear directions about what you want if you are incapacitated so they are legally empowered to make choices for you if you are unable to do so yourself. Do not count on generic legal protections; if you’re married, for example, and laws change or other circumstances happen, physicians may defer to a relative, which could mean that you have someone you don’t trust making decisions for you.