A Trans Guide to Fertility Research

As a certified trans fertility nerd™, I have all kinds of Google news alerts set for trans fertility topics. This means I receive a near-constant stream of notifications telling me about new studies, articles, and papers being published on the subject.

I’m a non-academic, so I’ve had to learn the hard way that not all research is created equal.

How can you make sense of the many pieces of information created right now? Here’s a quick guide to help!

Studies, Trials.

The absolute best kind of research is an actual study, where things like variables can be accounted for, and we aren’t relying on individuals to remember whether or not we did our shot at the same time every Friday, nor are providers giving after-the-fact recollections of whether they adequately counseled a trans youth on fertility preservation. I mean, who wants to admit that they forgot their shot or skipped a conversation with a patient?!

In a study, a cohort of patients is followed throughout a whole medical process, and things like counseling, medications, and hormones are delivered in a controlled setting, so everyone is receiving the same thing.

This kind of research is VERY RARE in the world of trans fertility. Some have looked at the impacts of HRT on sperm production, which are very helpful! But there simply aren’t enough of us concentrated in any area going through the same type of process simultaneously. So researchers usually use different tactics to gather and analyze information about trans fertility.

Case studies, Case reports. 

A case study is a published paper that looks at a very small number of people (as small as one or two individuals) and attempts to draw conclusions based on their medical experiences. Case studies and reports look at data that is qualitative (in-depth with a small group) rather than quantitative (large-scale, so you can make generalizations). These can tell us about specific lived experiences, bolstering empathy and understanding in ways that large-scale studies might not be able to.

For example, a case study looks at two trans women who attempted to regain fertility after HRT. There is also a case study looking at one trans youth who had been on puberty blockers and then attempted to complete egg harvesting before starting HRT.

You need case studies because often, as I mentioned above, you can’t do a major study because there aren’t enough people (or resources) available.

But!

Just because a single trans youth produced mature eggs for cryopreservation (yay!!!) doesn’t mean we can tell all trans youth that they’ll be able to do the same. In the trans women case study, one regained fertility and one didn’t. So does that mean that 50% of all trans women can produce sperm after HRT? Of course not! It means that of the two women studied, one could, and one couldn’t. That’s it.

Further, case studies and reports are more likely to skew towards patients who could pay for procedures or services outside of what insurance would cover. So they often focus on white, coastal, working-class to upper-class transgender people… which is not representative of our communities. 

Surveys.

These are great for gathering quantitative data because you can ask a LOT of people to provide information and insight into their experiences. You can then make broader generalizations because you’re looking at a thousand people’s experiences rather than one or two.

This also means you can “disaggregate” the data, which means putting people into categories and then comparing their experiences to see if there are notable differences between groups. For example, it is important to know that non-binary trans people experience worse transphobia during pregnancy than binary trans people do— that information can guide provider training and community advocacy efforts.

However!

One of the downsides of a survey is that we rely on individuals to accurately recall important events, which can be skewed by things like trauma, perinatal mood disorders, or even positive outcomes. Remember the adage that you forget the pain of childbirth once your baby is born? That certainly didn’t hold true for me (I remember every painful push), but you can see how our memories of events can be altered based on many different factors.

Articles and Papers. 

Because there are so many targeted, small studies on trans fertility (and other studies and surveys on cis people that can be applied to our situations), sometimes researchers will pour through everything and write reviews, articles, or papers summarizing all of that other research and drawing new conclusions (or pointing out disagreements that exist between other studies). These can be helpful if you aren’t interested in or able to read a dozen studies on a topic!

However, as discussed above… not all research is created equal. When you read an article, you’re counting on those researchers to catch any detail that may make one study more or less valid than another. I’ve seen articles referencing studies over a decade old or treating a two-person case study as equal to a 100+ person medical research study. So you have to pay close attention to the number of people in the studies analyzed in a paper and how long ago the study was published.

There are also articles or papers that attach theory to the experiences of trans reproduction. Theory can analyze overlapping systems of oppression and their reasoning, which can help us understand why imbalances occur in society. Theory and philosophical pontifications can useful, but we also need to be aware that these explorations can be deeply personal to the writer, or may be subject to change when new or conflicting information emerges. 

Other things to look for:

Sponsors.

If research is sponsored by a company or nonprofit that advocates for specific things (such as bodyfeeding, home birth, hospital birth, etc.), you may find some assumptions baked into the research. Be sure to read the intro paragraph so you understand the general ethos of the researchers. For example, if they want to answer the question of how to get more trans people to bodyfeed their babies, you might assume that the research isn’t a neutral look at feeding preferences in trans communities.

The number of study participants and demographic makeup of participants.

Case studies will include a few people, which may impact the universal conclusions. Surveys may have hundreds of participants, but if that survey was only distributed online, the participants might skew whiter, more urban, and younger. Researchers are usually good about naming these limitations, but by the time the work gets filtered through a paper and an article… those caveats may be missing. There is excellent research coming out of countries around the world, but those will also favor the demographics of that country. Denmark is 96% white, and they have socialized medicine. So studies coming out of Denmark are beneficial… with the understanding that their trans patient populations are quite different than those in the US.

Age of study.

The 2015 Light study is still great, as its findings have yet to be challenged by any subsequent study. However, in general… the older a study is, the less valid it is. HRT protocols have changed in the last ten years, and anti-trans legislation may impact hormone access now and into the future. Fertility preservation counseling has improved. WPATH standards have evolved and will continue to evolve to meet the changing needs of our communities. So pay attention to when a study was published, and apply a bit of skepticism if they’re more than a few years old.