Does Gender-Affirming Care Affect Fertility? A Sourced Guide for Families

TransHealthHub

Sep 14

4 min read

Key Takeaways

Supportive care for a transgender teen can affect future fertility, and the degree depends on which parts of that care a young person pursues and for how long, according to Mayo Clinic and the Endocrine Society.
Puberty-pausing medication limits reproductive development while it is in use; hormone therapy (estrogen or testosterone) carries a longer-term fertility risk that grows the longer treatment continues, especially when started before puberty.
The Endocrine Society's clinical practice guideline requires clinicians to counsel every young person on fertility preservation options before starting puberty suppression or hormone therapy of the affirmed gender.
A 2022 Stanford study of 132 transgender and non-binary adolescents found only 6.8 percent ultimately pursued fertility preservation, even though nearly a quarter accepted a referral for a formal consultation.
Research points to a real counseling gap: one review found only 58 percent of transgender and gender-diverse people reported adequate fertility counseling, and cost, typically $6,000 to $10,000 for egg retrieval and storage, is a major barrier.

The short answer on gender-affirming care

Yes, some forms of gender-affirming care can affect fertility, and how much depends on what a young person's care actually involves. Puberty-pausing medication pauses reproductive development for as long as it is used; hormone therapy (estrogen or testosterone) carries a fertility risk that grows with the length of treatment, particularly if started before puberty. Because of this, U.S. clinical guidelines require fertility counseling before either treatment begins, though research shows many families still don't get enough of it.

At TransHealthHub, we think families deserve to see exactly what current research says about fertility, not a single flat yes-or-no answer.

Readers may also see this called transition-related care or supportive care; whichever term appears, this page is describing the same category of medical, social, and psychological support for a transgender young person's transition.

Why fertility comes up in this care

Supportive care for a transgender adolescent can include social steps (name, pronouns, clothing), puberty-pausing medication, hormone therapy, and, for some, surgery later in adulthood. Fertility questions apply mainly to the medical pieces: puberty-pausing medication and hormone therapy. Mayo Clinic notes that feminizing hormone therapy "may limit fertility" and that "the risk of permanent infertility increases with long-term use," particularly when started before puberty; its page on masculinizing hormone therapy describes the same pattern for testosterone, adding that "even after stopping hormone therapy, the ovaries and uterus might not recover enough" for pregnancy without fertility treatment.

TransHealthHub's guides on estrogen therapy and testosterone therapy cover what starting each of these looks like in practice.

Fertility preservation counseling: what's required and what families report

The Endocrine Society's clinical practice guideline is direct on this point, recommending that clinicians "inform and counsel all individuals seeking gender-affirming medical treatment regarding options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy of the affirmed gender." That counseling is meant to happen before either treatment starts, not after.

In practice, research suggests this counseling doesn't always land the way it should. A 2024 narrative review of the fertility preservation literature found that only 58 percent of transgender and gender-diverse people reported adequate fertility counseling, 23 percent described it as inadequate, and 19 percent said they received none at all. The same review found that 49 to 67 percent of transgender adolescents said they wanted children eventually, a figure that complicates any assumption that fertility preservation isn't relevant to this age group.

What research shows about actually using fertility preservation

Wanting the option and using it are different things. A 2022 study of 132 transgender and non-binary patients, ages 10 and older, at Stanford's Pediatric and Adolescent Gender Clinic between 2015 and 2019 found that just 6.8 percent (9 patients) ultimately underwent fertility preservation, despite 24 percent accepting a referral for a formal consultation.

Transfeminine adolescents were more likely to pursue preservation than transmasculine adolescents (16.7 percent versus 2.3 percent). Among those who declined, the most common reason, cited by half, was simply not being interested in having biological children, at least not at that point in their lives. The 2024 review above identifies several broader barriers behind low uptake nationally: inconsistent timing of counseling, the cost of procedures like egg retrieval and storage (typically $6,000 to $10,000), concern that the preservation process itself can worsen gender dysphoria, and limited long-term research on outcomes.

Because interest in parenthood can change over time, both sources note that counseling works best as an ongoing conversation, not a single checkbox before treatment starts.

What's affected, and what to know

Type of care	Effect on fertility	What's recommended
Puberty-pausing medication	Pauses reproductive development while in use	Fertility counseling before starting
Estrogen therapy	Fertility risk increases with duration; risk is higher if started before puberty	Sperm preservation counseling before starting
Testosterone therapy	Fertility risk increases with duration; ovarian and uterine function may not fully recover after stopping	Egg, embryo, or ovarian tissue preservation counseling before starting
Fertility preservation itself	Used by a minority of adolescents offered it (6.8 percent in one study)	Repeated, not one-time, counseling as interest can change

Frequently asked questions

Does gender-affirming care affect fertility for all transgender teens? It depends on which parts of care a young person pursues. Social steps like name and pronoun changes don't affect fertility; puberty-pausing medication and hormone therapy can, with the risk generally growing the longer treatment continues.

Is fertility loss from hormone therapy permanent? It can be. Mayo Clinic notes that fertility may not fully recover even after stopping hormone therapy, which is why clinical guidelines call for fertility preservation counseling before starting rather than after.

How many transgender teens actually preserve their fertility before treatment? Uptake is low in the research so far, around 6.8 percent in one Stanford clinic study, even though a meaningful share of adolescents express interest in having children later.