Fertility Options for Couples Assigned Female at Birth

In cases with fertility issues, adoption and foster parenting are great options. However, if the couple is considering biological parenting, current medicine offers several alternatives. Let's explore the different fertility options for couples assigned female at birth.

Couples of two individuals assigned female at birth (AFAB) have several options to have children. These options might interest lesbian couples. But couples of a cis woman (AFAB woman identifying as a woman) and a trans man (AFAB individuals with a male gender identity) also would be interested in this topic.

Assisted reproduction with donor sperm

Advancements in reproductive medicine and legal regulations make assisted reproductive technologies (ART) accessible to most AFAB couples. Sperm could be used from a known or anonymous donor. Donor sperm could be utilized for intrauterine insemination (IUI) or in vitro fertilization (IVF).

• Intrauterine insemination. In IUI, sperms are injected into the womb cavity, and fertilization happens in the uterus.
• In vitro fertilization. In IVF, eggs collected from the AFAB individuals and donor sperm are fertilized in the laboratory environment, and the newly forming embryo is transferred into the uterus.

Artificially produced sperms

Science is advancing, and this advancement brings new options into the field. As in all other new treatment methodologies, new treatment options should be first evaluated in preclinical settings, and safety and efficacy should be proven. Only after these steps could new methods be implemented in humans.

Despite the availability of donor sperm, most couples desire to have genetically-related children. This need sparked more than two decades-long research focusing on sperm cell formation from somatic cells. Somatic cells are body cells differing from gonadal or sex cells in the number of chromosomal sets.

Sperms from embryonic stem cells

Studies successfully formed sperm cells from embryonic stem cells in mouse, rat, and monkey models. Researchers succeeded in developing mature and functional sperms and delivery of viable offspring in animal models.

Using embryos as a source to create sperm cells in humans has some limitations. First, these embryos are not genetically related to the patient. Also, this method is associated with ethical issues about the use of embryos derived from unrelated individuals.

Sperms from pluripotent stem cells

Recent studies focus on induced pluripotent stem cells (iPSCs), which could be generated from one’s somatic cells, such as skin fibroblasts, keratinocytes, peripheral blood cells, or kidney cells shed into the urine.

Despite successful results in mouse and rat models, some genetic factors introduce additional difficulties, resulting in a lower potential in humans.

However, science is open to discoveries, and we could discuss new perspectives in this field in the near future.

Pregnancy carrier

When it comes to carrying the pregnancy, AFAB couples have several options.

• Single or dual-partner conception. Lesbian couples may have fertility treatment for one partner or both partners. Literature suggests that, in 75-85% of cases, lesbian couples opt for single-partner and 15-25% for dual-partner conception.
• Reciprocal pregnancy. Lesbian couples may also choose a reciprocal pregnancy, meaning an egg is retrieved from one parent, and the pregnancy is carried in another parent’s womb. This option allows both partners to physically participate in pregnancy. In reciprocal pregnancy, embryos could be used immediately or frozen with a later transfer. If an immediate transfer is planned, then the cycles of both partners should be synchronized.
• Surrogacy. As an alternative option, a surrogate carrier could also be considered.

Limitations for conceivement

When we discuss fertility issues in AFAB couples, the need for a sperm source is a valid, but not the only point.

As simple as it might be thought, the egg cells or oocytes from two individuals are present in these scenarios. However, trans men undergo sex reassignment therapy, including surgical and hormonal methods.

Hormonal therapy

In these cases, hormonal therapy involves testosterone, male hormone preparations. The treatment aims to achieve male testosterone levels as quickly as possible. Consequently, the treatment will affect the menstrual cycle and result in menstrual cessation by six months to one year.

The effects of hormonal therapy could be reversed with the termination of the therapy. Literature suggests that long-term androgen exposure does not impair egg production, and testosterone-receiving individuals could produce healthy eggs with ovarian stimulation medications.

Transgender surgery

On the other hand, transgender genital surgery, including the removal of ovaries, will result in permanent loss of reproductive potential. In these cases, oocyte or embryo cryopreservation (freezing) might be considered prior to surgery.

It should be remembered that removing the womb (hysterectomy surgery) will limit the chances of carrying the pregnancy if desired.

Therefore, fertility counseling is recommended before gender reassignment surgeries.