Before they transition, some transgender youth preserve fertility by banking sperm or eggs
But first the teen who grew up in north suburban Wauconda faced one more weighty choice: whether to preserve his fertility — having his eggs harvested and frozen — prior to starting hormone therapy.
“The idea of having my own kids with my own eggs was, I guess, a pretty easy decision,” said Cabanban, now 21 and a junior at Michigan State University. “Even just having the option available … I knew I wanted to do that.”
Historically, many transgender people simply accepted potential loss of biological fertility as the price they paid to live according to their gender identity, which can involve hormone regimens and surgeries that might damage or destroy fertility.
But this mindset is shifting with advancements in assisted reproductive technology, many rooted in cancer treatment, said Diane Chen, a pediatric psychologist with the Gender and Sex Development Program at Ann & Robert H. Lurie Children’s Hospital.
Lurie began incorporating discussions of fertility and family planning into standard counseling for transgender and gender nonconforming youth about four years ago, drawing from the hospital’s already-established fertility preservation program for pediatric cancer patients, as cancer treatments can also affect fertility.
Cabanban was among the first of Lurie’s transgender patients to undergo fertility preservation, which is still a fairly uncommon practice.
Of 105 transgender adolescents treated at Lurie from 2013 to 2016, only 13 decided to see a fertility specialist for a formal consultation and five had their sperm or eggs frozen, according to a study published in the Journal of Adolescent Health in July.
In a survey of transgender patients in Toronto, 21 percent of childless respondents expressed interested in having kids but many said they lacked information about their fertility options or had never discussed the issue with a physician. Only 3 percent said they had sperm or eggs banked before starting hormone treatments, according to the research that was led by an endocrinologist and assistant professor at the University of Toronto and reported last year.
The British Fertility Society issued guidelines in January that medical providers discuss fertility implications with patients making the transition from female to male and, when appropriate, have eggs or ovarian tissue preserved as early as possible in treatment. The ethics committee of the American Society for Reproductive Medicine in 2015 recommended fertility preservation options be offered to all patients before a gender transition.
“Trans people are just as interested in having children as other people,” said Timothy Murphy, a professor of philosophy in the biomedical sciences at the University of Illinois College of Medicine at Chicago who has written on the topic.
Even with counseling, Chen said it can be difficult for young patients to contemplate their fertility a decade or more before they might want to conceive, without knowing what new reproductive options might emerge. Expense is also a barrier, with fertility procedures and storage fees potentially costing thousands of dollars and typically not covered by insurance.
For some, the intimate and invasive aspects of retrieving sperm and eggs can also magnify feelings of gender dysphoria, an intense discomfort with one’s biological sex.
“It’s not easy emotionally, it’s not easy physically,” Chen said. “Weighing the benefits and costs, that’s going to be different for each young person. How important is biological fertility to each young person — and how distressing would that process be?”
‘Making things better’
Cabanban remembers childhood nights lying awake in bed with his hands folded.
“I would pray to God to wake up a boy,” he said.
Whenever he played house with other little kids, he always wanted to be the dad. At 13, he typed “I’m a girl but I feel like a boy” into an online search engine and the word “transgender” appeared.
He kept the label to himself for roughly four years, before coming out to his parents and sister in 2015.
“I was never scared of anyone’s bad reaction,” he said. “Just the action of doing it was terrifying to me.”
Internet research taught him so much, from how to change a name legally to what side effects hormone therapy can cause. But he was surprised when Chen brought up his fertility, something he’d never thought of in relation to a gender transition.
Until about five years ago, egg banking was considered experimental, but this changed with improvements to freezing and thawing techniques.
Harvesting the eggs was a physically taxing process, requiring several weeks of daily estrogen injections that felt counter-productive to Cabanban, who longed to look and feel more masculine.
The day they were retrieved was one of the most uncomfortable moments of Cabanban’s life. With his still-feminine form covered in only a thin paper sheet, he watched his eggs on the ultrasound screen, white orbs that felt like foreign objects trespassing in his body.
The outpatient surgery was performed on Father’s Day. Around 20 of his eggs were harvested and remain frozen in a warehouse in Minnesota, waiting.
Now that they are no longer inside him, Cabanban says he views the eggs only as a tool for reproduction, the potential to pass down his DNA; that they are female in nature doesn’t really bother him.
Chen says this isn’t the case for everyone.
“There’s been some research … of adult transgender individuals who have reported that it’s difficult for them to leave behind their birth-assigned sex and live authentically in their affirmed gender knowing they have eggs or sperm — something that doesn’t match or isn’t in alignment with their gender identity — saved,” she said. “That idea to them didn’t feel right or was distressing.”
Cabanban hopes to one day have a hysterectomy and sex reassignment surgery, which would render him infertile. He doesn’t know if he’ll ever have biological children, but he’s grateful for the option.
Perhaps someday he’ll get married, he said, and his wife will carry the eggs he saved in her womb.
“I want to teach my kids what my parents have taught me,” he said. “My dad always says … you want to take the mistakes your parents made and make it better for your kids, and just keep making things better and better as life goes on. I want to take what I learned from them and try to make things as good as I can for my kids and future generations.”
Chen said it’s often the parents of patients who broach the topic of fertility.
Cabanban’s mother, Carolyn Cabanban, recalled some of her first words to her son after his eggs were harvested.
“I’m a grandmother,” she said.
Concept of parenthood
It was during middle school that Juniper Schenone of Naperville realized her sense of self and then-male body were in conflict.
“Imagine waking up every single day and you look in the mirror and you just feel off,” she said. “You didn’t really know why, but you look in the mirror and you would just not like what you see, and you want to change things about yourself.”
By high school, she identified as a transgender woman, growing out her hair and wearing makeup and dressing more femininely.
Schenone, 18, went on estrogen in August before starting as a freshman at Columbia College. She was in a long-term relationship when she began treatment at Lurie, which she says gave context to her decision to bank sperm over the summer.
“Biological fertility was definitely important to me, having the availability to pass down my genes and have that emotional connection,” she said.
Although she lives as a woman, Schenone said she identifies more with the concept of parenthood than motherhood.
“Because I feel motherhood sort of has the process of being pregnant and going through that state, through the nine months, that gives you that connection with your child,” she said. “Whereas I’ll never be able to experience that.”
While Schenone said these physical limitations don’t bother her— she’s not even sure she’d desire to carry a child or give birth — Chen said this can be painful for others.
“I have had some of my younger trans girls — these are 9-, 10-, 11-year-old birth-assigned boys who identify and are living as girls — they really associate motherhood and being pregnant with being a girl, a woman,” she said. “And that’s a difficult conversation for us as practitioners and also for parents to navigate with youth, in terms of what it means to be a parent and what it means to be a mother.”
Some youth are hoping for scientific and medical breakthroughs by the time they’re ready to start families.
Very young transgender patients sometimes freeze tissue from their ovaries or testes for later use, a method that’s still considered experimental. In November, a woman with a uterus transplant delivered a healthy baby boy at Baylor University Medical Center at Dallas, another highly experimental procedure.
Scientists at Northwestern University Feinberg School of Medicine announced recently that they’d created 3-D printed bioprosthetic ovaries allowing mice to ovulate, give birth and nurse their young, said Teresa Woodruff, director of the Women’s Health Research Institute at Northwestern. The hope is to restore fertility and hormone production in cancer survivors, but transgender patients might also one day benefit.
While these prospects are exciting, Chen said she tries to focus on technology that’s available today when helping youths make decisions, because she doesn’t want to give them false hope. Even though discussing fertility is important, Chen also explores different forms of parenthood with patients, including adoption and surrogacy.
“We know there are a lot of different ways to have a family,” she said. “Biological parenthood is just one of those ways.”