Testosterone therapy is a vital component of gender-affirming care for many transgender men and non-binary people assigned female at birth. Whilst testosterone significantly suppresses ovarian function and reduces fertility during active treatment, questions about conception after stopping testosterone are common and important. Understanding how testosterone affects reproductive capacity, the potential for fertility restoration, and available preservation options is essential for informed decision-making. This article examines current evidence on conceiving after testosterone treatment, fertility preservation strategies, pregnancy considerations, and NHS support pathways for transgender individuals navigating reproductive choices.

How Testosterone Therapy Affects Fertility in Transgender Men

Testosterone therapy is a cornerstone of gender-affirming treatment for many transgender men and non-binary people assigned female at birth. Understanding its impact on fertility is essential for informed decision-making before commencing treatment.

Mechanism of Action and Reproductive Effects

Testosterone works by binding to androgen receptors throughout the body, promoting masculinisation and suppressing the hypothalamic-pituitary-ovarian axis, which reduces endogenous oestradiol production. When administered at therapeutic doses, testosterone typically leads to cessation of menstruation (amenorrhoea) in most individuals within 2–6 months. This hormonal shift inhibits ovulation, significantly reducing—but not eliminating—the possibility of conception whilst on treatment.

The degree of ovarian suppression varies between individuals. Whilst many transgender men experience complete cessation of ovulation, some may continue to ovulate intermittently, particularly in the early months of treatment or with suboptimal testosterone levels. It is crucial to understand that testosterone is not a reliable contraceptive method, and pregnancy can occur during treatment, albeit uncommonly. Effective contraception (such as IUDs or progestogen-only methods, which are compatible with testosterone) is recommended for sexually active individuals who could become pregnant. If pregnancy is suspected while taking testosterone, stop treatment immediately and seek urgent medical advice, as testosterone is contraindicated in pregnancy.

Long-term Reproductive Changes

Prolonged testosterone therapy may lead to structural changes in reproductive organs, including endometrial atrophy and alterations to ovarian tissue. However, the extent and reversibility of these changes remain areas of ongoing research. Current evidence suggests that whilst testosterone significantly impacts fertility during active treatment, the effects may not be entirely permanent in all cases. The duration of testosterone use, dosage, individual physiology, and age at initiation all influence potential fertility outcomes, making personalised counselling essential before starting treatment.

Can You Conceive After Stopping Testosterone Treatment?

The question of fertility restoration after discontinuing testosterone therapy is complex and varies considerably between individuals. Current evidence suggests that conception is possible for many transgender men after stopping testosterone, though outcomes are not guaranteed.

Evidence for Fertility Return

Multiple case reports and small cohort studies document successful pregnancies in transgender men who have discontinued testosterone therapy. Menstruation typically resumes within 1–6 months of stopping treatment in many individuals, suggesting restoration of ovarian function. However, the timeframe for return of fertility is highly variable and influenced by factors including duration of testosterone use, age, baseline ovarian reserve, and individual physiology.

Research indicates that younger individuals and those with shorter durations of testosterone exposure may experience more rapid and complete fertility restoration. Conversely, those who commenced testosterone at older ages or used it for extended periods may face greater challenges, though successful conception has been documented even after many years of treatment.

It's important to note that ovulation may resume before the first menstrual period returns, so contraception is advisable until actively trying to conceive.

Uncertainties and Individual Variation

It is important to acknowledge that there is no official guarantee of fertility restoration after stopping testosterone. Some individuals may experience permanent changes to reproductive function, whilst others regain fertility relatively quickly. Some studies suggest polycystic ovary syndrome (PCOS) may occur at higher rates in transgender men than the general population, though evidence is limited and heterogeneous. PCOS may independently affect fertility regardless of testosterone use.

Clinical Recommendations

For transgender men considering pregnancy after testosterone therapy, consultation with reproductive endocrinology specialists is advisable. UK guidelines suggest referral to fertility services after 12 months of trying to conceive (or 6 months for those aged 35 and over), though earlier referral may be appropriate after prolonged testosterone exposure. Baseline fertility assessments, including ovarian reserve testing (anti-Müllerian hormone levels, antral follicle count) and hormonal profiling, can provide valuable information about reproductive potential. Individuals should be counselled that whilst many achieve pregnancy after discontinuing testosterone, outcomes vary, and fertility preservation before starting treatment remains the most reliable option for those desiring biological children.

Fertility Preservation Options Before Starting Testosterone

For transgender men who wish to retain the option of biological parenthood, fertility preservation before commencing testosterone therapy offers the most reliable pathway. Several evidence-based options are available through NHS gender identity services and fertility clinics.

Oocyte (Egg) Cryopreservation

Oocyte freezing involves ovarian stimulation with hormonal medications to produce multiple mature eggs, which are then retrieved via a minor surgical procedure and cryopreserved. This process typically requires 2–3 weeks of daily hormone injections and monitoring appointments. Whilst some transgender men find the feminising effects of ovarian stimulation distressing, protocols can be modified to minimise discomfort, and the process is time-limited.

Success rates for future pregnancy using frozen oocytes depend on age at freezing, with higher success rates in younger individuals (typically under 35 years). The NHS may fund fertility preservation in some circumstances, though availability varies by region and Integrated Care Board (ICB) in England, with different arrangements across Scotland, Wales and Northern Ireland.

Embryo Cryopreservation

For those with a partner who can provide sperm, embryo freezing offers another option. This involves the same ovarian stimulation and egg collection process, followed by in vitro fertilisation and freezing of resulting embryos. Embryos generally have slightly higher survival and implantation rates compared to unfertilised oocytes, though this option requires a sperm source at the time of preservation.

Ovarian Tissue Cryopreservation

This technique involves surgically removing and freezing ovarian tissue for potential future reimplantation. It is established in oncology settings at selected UK centres but has limited data and availability for transgender indications. It may be appropriate for younger individuals or those unable to delay testosterone therapy for ovarian stimulation, but requires specialist referral and is not widely accessible.

Practical Considerations

Fertility preservation requires careful planning and can delay gender-affirming treatment by several weeks to months. Comprehensive counselling should address the emotional, financial, and practical implications. Under the Human Fertilisation and Embryology Authority (HFEA) regulations, gametes and embryos can be stored for up to 55 years with appropriate consent, though regular consent reviews are required. NHS England's Adult Gender Dysphoria Service Specification and professional guidelines from organisations such as the World Professional Association for Transgender Health (WPATH) recommend that all individuals commencing gender-affirming hormone therapy should receive information about fertility preservation options and be offered referral to specialist fertility services where appropriate.

Pregnancy Considerations for Transgender Men After Testosterone

Transgender men who become pregnant after testosterone therapy face unique medical and psychosocial considerations. Understanding these factors is essential for safe pregnancy management and optimal outcomes.

Discontinuing Testosterone During Pregnancy

Testosterone must be discontinued before attempting conception and throughout pregnancy as it is contraindicated in pregnancy according to UK medicines guidance. The MHRA Summary of Product Characteristics for testosterone products indicates potential risks of virilisation to a developing foetus. Individuals should stop testosterone therapy and plan conception under specialist care, typically waiting until menstruation and ovulation resume, though this timeframe varies individually. If pregnancy occurs while taking testosterone, the medication should be stopped immediately and urgent medical advice sought.

Pregnancy-Related Health Considerations

Limited but growing evidence suggests that previous testosterone use does not necessarily increase pregnancy complications when the hormone is discontinued appropriately. However, several factors warrant careful monitoring:

• Polycystic ovary syndrome (PCOS): Some evidence suggests PCOS may be more common in transgender men, which could increase risks of gestational diabetes and pregnancy-induced hypertension, potentially requiring enhanced surveillance.

• Endometrial changes: Prior testosterone-induced endometrial changes typically reverse after treatment cessation, with standard antenatal care being appropriate unless clinically indicated otherwise.

• Chest/breast tissue changes: Previous chest masculinisation surgery may affect the ability to chestfeed, though this varies depending on surgical technique and individual anatomy.

Psychological and Social Support

Pregnancy can be emotionally complex for transgender men, potentially triggering gender dysphoria due to physical changes and social perceptions. Access to gender-affirming mental health support throughout pregnancy is crucial. NHS perinatal mental health services can provide support, though familiarity with transgender healthcare varies. Healthcare providers should use appropriate terminology (e.g., "pregnant person" rather than assuming "mother"), respect chosen names and pronouns, and provide sensitive, individualised care.

Antenatal Care Pathways

Transgender men should receive standard antenatal care, with additional consideration for gender-affirming support. Multidisciplinary care involving obstetricians, midwives, gender identity specialists, and mental health professionals optimises outcomes. Individuals should be advised to inform their healthcare team about previous testosterone use to ensure appropriate monitoring and support throughout pregnancy and the postnatal period. Resuming testosterone is generally not recommended while chest/breastfeeding and should be discussed with a specialist.

NHS Support and Guidance for Transgender Fertility

The NHS provides various pathways for transgender individuals seeking fertility advice, preservation, or pregnancy support, though access and provision vary across the UK.

Gender Identity Clinic Services

NHS Gender Identity Clinics (GICs) are the primary access point for gender-affirming care, including fertility counselling. Before prescribing testosterone, clinicians should discuss fertility implications and preservation options according to the NHS England Adult Gender Dysphoria Service Specification and professional guidelines. However, waiting times for GIC appointments can be substantial in many regions, which may prompt some individuals to access private gender-affirming care whilst seeking NHS fertility services separately.

Fertility Preservation Funding

NHS England's service specifications indicate that fertility preservation should be discussed with individuals undergoing treatments that may affect fertility, including gender-affirming hormone therapy. However, funding decisions are made by local Integrated Care Boards (ICBs) in England, with different arrangements in Scotland, Wales and Northern Ireland, resulting in significant regional variation. Some areas provide comprehensive funding for oocyte or embryo freezing, whilst others offer limited or no provision. Individuals should enquire about local policies through their GIC or GP.

The NHS typically covers initial fertility preservation procedures, though storage fees may apply after an initial period. Private fertility preservation costs vary considerably between clinics, plus ongoing storage fees. It's advisable to check current prices with individual clinics.

Accessing Specialist Support

Transgender individuals can access fertility services through several routes:

• GP referral: General practitioners can refer directly to NHS fertility clinics for assessment and preservation procedures.

• Gender Identity Clinic referral: GICs can facilitate referrals to fertility specialists familiar with transgender healthcare.

• Self-referral to private clinics: Some individuals choose private fertility services for faster access, with costs varying by provider and treatment.

The Human Fertilisation and Embryology Authority (HFEA) provides a clinic finder tool and information about services across the UK.

Pregnancy and Postnatal Care

NHS maternity services are increasingly developing transgender-inclusive care pathways. Individuals should inform their midwifery team about their gender identity and previous testosterone use to ensure appropriate, respectful care. Many NHS trusts now offer training in transgender healthcare for maternity staff, though experiences vary. If concerns arise about discriminatory treatment, individuals can contact the Patient Advice and Liaison Service (PALS) or seek support from transgender advocacy organisations such as TransActual UK or LGBT Foundation, which provide guidance on navigating NHS services and understanding rights under the Equality Act 2010.

Any suspected adverse effects related to testosterone treatment, including pregnancy exposure, should be reported through the MHRA Yellow Card scheme.

Frequently Asked Questions