Table 2 Reproductive considerations for medical and surgical transition

When discussing transition options with patients, discuss the reproductive consequences. These are salient points to cover:

Testosterone:

 - Testosterone should not be considered a form of contraception [1].

 - Patients should avoid getting pregnant while taking Testosterone – it is considered a teratogen [5].

 - Conception and pregnancy can occur after even long-term testosterone use [1].

 - Testosterone likely decreases conception rate through ovarian suppression, however we can’t currently quantify the direct impact on ovulation or conception rates.

 - If genetically related children are desired or potentially desired in the future, consider storing oocytes or embryos prior to initiating testosterone. (Note: ovarian tissue preservation is still considered experimental) [25,26,27,28,29].

 - Patients need to stop testosterone in order to pursue carrying a pregnancy.

 - If genetic children are desired after initiation of testosterone, testosterone should be stopped. The determination of whether and to what extent assisted reproductive technologies (ART) will be used will depend on the trans man’s a) desire to carry the pregnancy, b) presence of normal menstrual cycle, and c) the desired method of joining sperm and egg [25, 28, 29].

Chest surgery:

 - Chest feeding may be possible after certain forms of chest reconstruction [5, 30].

 - It is not possible to tell prior to attempting to chest feed whether this is possible based on type of surgery, chest anatomy etc.

 - Discuss the likely impact of various surgical approaches on ability to chest feed / lactate.

 - Discuss methods used by transgender men to chest feed after chest reconstruction.

 - Encourage the patient to discuss these issues with their surgeon (ideally prior to surgery).

 - Encourage lactation support if desired.

 - If chest feeding is not possible or not desired discuss other methods for infant feeding and bonding.

Genital surgery:

 - Metoidioplasty, scrotoplasty, or phalloplasty do not, by themselves, impair future reproductive options, but would likely necessitate a cesarean section for delivery.

 - Vaginectomy combined with hysterectomy and/or oophorectomy would eliminate the chance of future pregnancies. If patients might want biological children someday, they should consider storing oocytes, or embryos prior to genital surgery. Ovarian tissue preservation is still considered experimental [28].

Postpartum Testosterone: The effects of taking testosterone while lactating are unknown. There are possible risks to the child, but no clear evidence of harm. The benefits to the parent’s mental, emotional, physical and social wellbeing are likely highly variable, and best evaluated by the patient.

- If a patient does resume or initiate testosterone while nursing, counsel them on how to look for signs of androgen exposure in the infant and encourage them to let their child’s pediatrician know.