Does testosterone therapy affect fertility in a female-to-male (FTM) person?

Does Testosterone Therapy Affect Fertility in Female-to-Male Persons?

Yes, testosterone therapy significantly impairs fertility in female-to-male (FTM) transgender individuals through suppression of the hypothalamic-pituitary-gonadal axis, but emerging evidence demonstrates that fertility can often be preserved or restored, and successful pregnancies have been achieved both during and after testosterone use. 1, 2

Mechanism of Fertility Impairment

Testosterone therapy causes negative feedback on the hypothalamus and pituitary gland, resulting in:

• Suppression of gonadotropin-releasing hormone (GnRH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH), which are essential for ovarian function and oocyte maturation 3, 4, 5
• Cessation of menstruation in most patients, typically within 3 months of initiating therapy 1
• Structural changes to reproductive organs, including the ovaries, uterus, and fallopian tubes, though the reversibility and functional impact remain incompletely understood 2

Critical Evidence on Fertility Preservation and Recovery

Fertility After Testosterone Exposure

Recent high-quality evidence demonstrates that successful oocyte retrieval, embryo cryopreservation, and live births are achievable in FTM individuals with prior testosterone exposure:

• Successful fertility treatments including IVF, embryo cryopreservation (averaging 3+ high-quality blastocysts), oocyte cryopreservation (averaging 19.3 ± 16.2 mature oocytes), and intrauterine insemination have been documented in FTM individuals with testosterone history 6
• All patients who completed IVF or embryo cryopreservation produced high-quality blastocytes, and this is the first evidence showing successful IUI cycles in patients with prior testosterone use 6
• No correlation exists between duration of testosterone use, time off testosterone, and fertility outcomes in terms of oocytes retrieved or treatment success 6

Ovarian Response After Testosterone

• Ovaries remain responsive to gonadotropin stimulation even after testosterone exposure, producing fertilizable eggs when stimulated, though ovarian size may be reduced 7
• Pregnancies have been documented in FTM individuals after testosterone use, though the predictability of these outcomes remains uncertain 2

Clinical Decision Algorithm for Fertility Management

For FTM Individuals Planning Testosterone Therapy

Fertility preservation counseling should be offered before initiating testosterone, but logistical and practical barriers prevent many from accessing these options. 2, 8

• Standard recommendation: Oocyte or embryo cryopreservation prior to testosterone initiation 1, 2
• Barrier acknowledgment: Many FTM individuals cannot or do not pursue fertility preservation before starting testosterone due to cost, access, or urgency of gender-affirming care 2, 8

For FTM Individuals Currently on Testosterone Desiring Fertility

Two approaches exist, with emerging evidence supporting continued testosterone use during ovarian stimulation:

Traditional Approach (Testosterone Cessation):

• Discontinue testosterone for ovarian stimulation, though the required duration of cessation is unclear and not directly correlated with outcomes 8, 6
• Major limitation: Testosterone withdrawal causes significant gender dysphoria, anxiety, and psychological distress 8

Emerging Approach (Continued Testosterone):

• Recent evidence suggests oocyte retrieval is viable without testosterone cessation, with no direct relationship between duration of testosterone suspension and fertility outcomes 8
• Aromatase inhibitors during ovarian stimulation may reduce distressing effects of hormonal ovulation induction while on testosterone 8
• This approach requires further research but shows promise for reducing gender dysphoria during fertility treatment 8

Common Pitfalls and Caveats

Critical Counseling Points

• Fertility preservation should be discussed before testosterone initiation, but the absence of pre-treatment preservation does not preclude future fertility options 2, 6
• Recovery of fertility after testosterone is possible but unpredictable, with variable timelines and uncertain success rates 2
• Long-term testosterone effects (beyond 6 weeks in animal models, years in humans) on reproductive capacity remain incompletely characterized 2, 7

Monitoring Considerations

• Baseline fertility assessment is not routinely required before testosterone initiation in FTM individuals, unlike the male fertility guidelines which recommend semen analysis 3
• Contraception counseling remains essential, as pregnancy is possible even with menstrual suppression on testosterone 1

Key Distinction from Male Testosterone Therapy

The fertility effects of testosterone in FTM individuals differ fundamentally from testosterone replacement therapy in cisgender males:

• In cisgender males, exogenous testosterone is absolutely contraindicated when fertility is desired, with recovery taking months to years and potential irreversibility 9, 3
• In FTM individuals, ovaries retain responsiveness to gonadotropin stimulation even after testosterone exposure, with documented successful outcomes 7, 6