Regaining Sperm Cells After HRT
Study Finds: Nine transgender women able to create mature sperm cells after pausing HRT
By Vann Jones
A study released earlier this year documented nine transgender women in the Netherlands and Australia as they paused hormone replacement therapy (HRT) in order to create mature sperm. By 17 weeks, or nearly four months, all individuals were able to produce spermatozoa (mature sperm cells). And three of the four trans women who stopped HRT to conceive at home with a partner were able to do so.
Before going into the data and findings, let’s tackle the limitations of this study, as there are quite a few.
Data such as the race/ethnic background of each participant was not collected, so it is difficult to determine if the study was diverse enough to accurately represent the transfeminine population at large.
As with nearly all studies on transfeminine fertility and the effects of HRT, there are few with adequately large sample sizes that can deter the possibility of error. A study with a sample size of nine is more comparable to a case study, rather than a large survey that can accurately represent the population it means to act as a stand-in for.
One example of an uncontrolled variable that affected the data was a participant who moved across continents and was separated from her partner for a substantial time after stopping HRT, which is likely what contributed to the extended amount of time it took to conceive.
There was a lack of data collected on the semen quality of the participants before and during HRT, and so it is quite possible that some individuals could have had abnormal semen qualities before hormones were introduced. In the case of the one trans woman who was unable to conceive with her partner, without a sperm analysis prior to HRT, there is no way of telling if she had ever had viable sperm in the first place.
While participants of the study were off of HRT, the monitoring of hormone levels was haphazard and the timing of semen collection differed between each individual, making it difficult to draw comparisons.
With that being said, let’s look at the participants of the study and what the outcomes were. The nine participants were between the ages of 18–32 years old, and they had all been on estrogen in combination with an anti-androgen such as spironolactone or cyproterone acetate for a duration of 6–216 months. Seven individuals had been on a daily regimen of 2-4 mg of oral estradiol, and two had been on topical estradiol. Four of the nine women had stopped HRT in order to attempt to conceive with their current partners, whereas the other five stopped in order to collect and preserve sperm for future reproductive purposes.
The first attempt to collect sperm happened between 3-27 months after stopping HRT (with the higher number occurring due to the participant who moved across continents, as mentioned above). Six women had sperm present during their initial semen analyses, whereas three exhibited azoospermia (no sperm in their semen) at 1, 4, and 7 months of initial analyses. Two of these participants were able to create mature sperm at 8 and 10 months, and the final woman had testicular sperm extraction at 17 months in which she was able to recover mature sperm.
In terms of the quality of the sperm collected, four people were able to produce a sample of semen with qualities falling in the normal range, and four produced lower quality sperm. There was no obvious correlation between the amount of time a person had been on HRT and the timing of when spermatozoa were able to be detected. Three of the four trans women who stopped HRT with the hopes to naturally conceive with their partners were able to do so after 4, 20, and 40 months (the last number reflecting the participant who was away from her partner for many months, as discussed earlier). The last individual has not reported a natural conception as of 28 months after stopping HRT.
While this study can be used to refute broad claims both at the political and medical level that HRT will always lead to permanent infertility, the small size of this study limits any specific estimation of the numbers of trans women who are able to a) create spermatozoa and b) conceive after pausing HRT. Going forward, this study points to the need to create larger studies with proportionally accurate sample sizes that can represent the transfeminine community at large.
Additionally, while considering how this study may impact medical advice given to transgender women looking to start HRT, it’s highly recommended that all individuals conduct a sperm analysis in order to evaluate whether any pre-existing conditions might impact future fertility. In the United States, sperm analysis is often covered by medical insurance as preventative care and should be somewhat easy to access. The authors rightfully state that all providers should inform patients of their ability to collect, freeze, and store their sperm before beginning any prescription estrogen or anti-androgen.
The authors cite that this study may influence some to be less inclined to bank their sperm before starting HRT, knowing that they may be able to produce sperm later on. However, the study fails to consider the emotional impacts of pausing HRT for the amount of time necessary to create spermatozoa. Upon reverting back to physical characteristics present prior to transitioning, some (but not necessarily all) trans women may experience heightened gender dysphoria and mental distress. For some, conducting sperm analysis and preservation before HRT may still be the best route. Reducing barriers to accessing fertility preservation and reproductive procedures (such as cost, comfort, and education) is expected to help improve both reproductive and mental health outcomes for the transfeminine community going forward.
