This guide was created in collaboration with Dr. Izzy Lowell, founder of QueerMed and a gender-affirming care provider partnered with Point of Pride’s HRT Access Fund program.
At some point during your transition, you might pause and ask, "Do I want to keep the option of having biological children open?"
We hear this question from many trans women at different stages of their journey. It can come up before starting hormones, years into treatment, or unexpectedly during a medical appointment.
For some, the answer feels clear, whereas for others, it’s shaped by timing, access, finances, safety, or simply not having all the information yet.
However you arrived here, you’re not behind. This guide focuses on how HRT can affect fertility, so you can make a decision that feels right for you.
Estrogen and testosterone-suppressing medications commonly reduce sperm production.
Estrogen lowers the amount of testosterone circulating in the body. Because testosterone plays an important role in sperm production, lower levels often mean sperm counts decrease or stop altogether.
Outcomes vary widely, and research is still evolving. There’s no reliable way to predict how HRT will affect fertility for any one person, or how quickly it will happen. Because of this uncertainty, some people choose to preserve fertility before starting hormones. Others decide not to. And some revisit the question later.
In an ideal logistical world, fertility preservation happens before starting HRT. But life is rarely ideal or perfectly timed. If you’re not sure what you want yet, or if you're on the fence with any aspect of a medical transition, talking with a provider early can help you understand your options and make the right decisions for your care and future.
Take a breath. Starting HRT does not automatically mean your fertility is permanently gone. There’s no universal timeline that you “missed.”
Many people are still able to preserve fertility after beginning hormones. This often looks like pausing hormones for a few months under medical supervision. (We know even the idea of stopping hormones can feel difficult. Dysphoria, anxiety, or emotional distress may increase during a pause. But if this is ultimately the right path for you, it's something other trans folks have navigated, too. It's possible. We recommend you just take extra care and lean on your support networks more during this time.)
There’s a lot of mixed information online. Here are a few clarifications:
Myth: Estrogen immediately causes permanent infertility.
Reality: Suppression can happen quickly for some people, but permanent infertility isn’t guaranteed.
Myth: If you can still ejaculate, you’re fertile.
Reality: Ejaculation doesn’t necessarily mean viable sperm is present.
Myth: If you’ve been on HRT for years, it’s too late.
Reality: Some people are still able to preserve fertility after extended hormone use, but outcomes vary.
Myth: If you stop HRT, your fertility will return.
Reality: Fertility may return for some people, but not for everyone.
You don’t need perfect or even complete answers to any of these questions. They're just here to help you notice what matters to you and navigate decision-making:
For many trans women, decisions around fertility and family planning are all shaped by timing, cost, access to care, and current priorities. It may feel like a big, complicated hypothetical—and not the most urgent need in your life right now. That's valid.
Fertility preservation is one option to consider, but it’s not something everyone chooses—or has access to. The goal isn’t to make a perfect decision. It’s to have enough information to decide what makes sense for you right now.
Biological connection isn’t the only path to parenthood. Families are built through adoption, fostering, co-parenting, assisted reproduction, and chosen family. Love really does make a family!