Human Reproduction Vol.16, No.4 pp. 612–614, 2001

DEBATE—continuedGender reassignment and assisted reproduction

identity disorder’. Transsexualism is now generally recognizedPresent and future reproductive options forto be a condition that needs to be treated by state-of-the-arttranssexual peoplehormonal and surgical therapy to obtain reassignment to thedesired gender [see also the standards of care in (Levine et al.,Paul De Sutter1

1998)]. Reassignment therapy normally only takes place afterInfertility Centre, University Hospital Ghent, De Pintelaan 185, psychiatric evaluation to rule out co-morbidity, and surgery isB-9000 Gent, Belgium. moreover only performed after a successful ‘real life test’,

which means that the individual must have lived a specified1To whom correspondence should be addressed. amount of time (usually one or two years) in the desiredE-mail: paul.desutter@rug.ac.be

gender role.Until recently, transition to the desired gender and reproduc-Transsexual people who want transition to their desired

tion seemed to be mutually exclusive for transsexual people.gender have to undergo hormonal and surgical treat-To many, loss of reproductive potential seems the ‘price toments, which lead to irreversible loss of their reproductivepay’ for transition. Even today, many medical experts—evenpotential. This paper argues that transsexual people shouldthose involved in the care for transsexual and transgenderedbe offered the same options as any person that risks losingpeople—are still critical when discussing possible procreationtheir germ cells because of treatment for a malignantafter gender reassignment. However, recent publications havedisease. Indeed, transsexual women (male-to-femaleopened the ethical debate as to whether transsexual peopletranssexual patients) may be given the option to storeshould be helped in their possible wish for children inspermatozoa before they start hormonal therapy, so thatrelationships occurring after transition (Brothers and Ford,their gametes may be used in future relationships. This2000; Jones, 2000). The debate has only just started amongstmay be especially important for the many transsexualfertility experts and currently only deals with donor insemina-women who identify as lesbians after their transition.tions in female partners of transsexual men (female-to-maleConversely, transsexual men (female-to-male transsexualtranssexual patients). The question posed is whether transsexualpatients) may be offered storage of oocytes or ovarianpeople can be ‘good’ parents, without negative influence ontissue, possibly obtained at the time of their oophorectomy.the gender and/or sexual orientation of the child-to-be, aCurrent technology offers transsexual people the possibilitydiscussion that was held many years ago for homosexualto obtain children who are genetically their own in theirpeople (Hanscombe, 1983). As it was to homosexuals then,

future relationships and the option of gamete bankingthis question may be considered to be an insult to transsexual

should therefore be discussed before starting hormonalpeople, and we rather believe that the debate should be

and surgical reassignment treatment. This is particularlybroadened and discuss the possibilities of how to help fulfil

important for transsexual people who are diagnosed andthe wish for children by transsexual people, rather than whether

treated at a young age. to help them or not. The overall wellbeing of transsexual peopleafter gender reassignment therapy has been well documented in

Key words: gamete preservation/reproduction/sperm freezing/recent studies (Cohen-Kettenis and Gooren, 1999) and many

transsexual/transgenderof these people have normal relationships with children fromtheir previous relationships or from their current partners.

More and more, people are diagnosed and treated for theirtranssexuality at an early age, when they still do not have

Introduction any children nor possibly any wish for children. RecentTranssexualism (Benjamin, 1966) is the most extreme form of reproductive techniques, however, have made it possible togender dysphoria (Fisk, 1973), which means that an individual preserve germ cells for future use, so that in theory transsexualhas a feeling of belonging to the gender opposite to his or her people may make use of their germ cells after transition. Aown gender, as determined by his or her primary and secondary few years ago Lawrence et al. discussed the ‘reproductivesexual characteristics. Although transsexualism has long been needs’ of the transsexual patient (Lawrence et al., 1996),thought of as a mental disorder, evidence clearly shows that taking Lawrence’s ideas further, the purpose of this paper isthis is not the case (Haraldsen and Dahl, 2000). The diagnosis to discuss what is already technically possible now, and what‘transsexualism’ per se has been removed from the Diagnostic may be possible tomorrow. Of course, we may expect that theand Statistical Manual of Mental Disorders (Fourth Edition) medical and ethical debate will continue before these new

techniques may be implemented routinely.(APA, 1994) and replaced by the more general term ‘gender

612 © European Society of Human Reproduction and Embryology

Reproductive options for transsexuals

The right to procreate Transsexual men

For transsexual men the same principles apply. MasculinizingIn modern reproductive medicine it is generally accepted thatevery person has the right to procreate (Robertson, 1987; hormonal therapy will lead to a reversible amenorrhea but

ovarian follicles will remain in place. There is some discussionSchenker and Eisenberg, 1997). For the transsexual patientthis does not seem obvious. The problem is that hormonal and/ as to whether this leads to a condition similar to polycystic

ovarian syndrome, (Pache et al., 1991). Of course castrationor surgical treatments have rendered procreation biologicallyimpossible. In daily infertility practice, however, there is will provoke irreversible ovarian failure. To preserve procre-

ational potential three options are available: oocyte banking,another example where procreation is impossible by naturalmeans. Reproduction within lesbian couples is nowadays more embryo banking and ovarian tissue banking. We will only

briefly discuss these options, since their technicalities do notand more accepted and both simple donor inseminations andcross-over IVF (one woman provides the oocytes, which after belong to the scope of this paper.fertilization in vitro are transferred to her partner) are performedto help fulfil the wish for children of lesbian women. Many

Oocyte bankingstudies have shown that the children are developing in exactlyOocyte banking requires hormonal stimulation and oocytethe same way as children from heterosexual parents (Brewaeysretrieval (as for IVF) and subsequent freezing of the oocytes.et al., 1997; Chan et al., 1998) and this has made homosexualAlthough this option would be very interesting, mature oocytesprocreation socially and medically more acceptable. The argu-seem very vulnerable to chromosomal damage by the freezingment that the transitioning transsexual patient has deliberatelyand thawing process. The very poor survival of the oocyteschosen to abandon his or her reproductive potential, is of theafter thawing, and poor fertilization and implantation resultssame nature as saying that a woman becomes a lesbian byafter IVF still make this a non-realistic strategy. Only a fewchoice. If we accept that lesbianism is not a matter of choicebirths have been reported in the world (Chen, 1986) andand we accept that lesbian mothers-to-be may well be helpedoocyte banking besides would also require the use of donorwith their wish for children, the same should apply to trans-spermatozoa and a recipient uterus of a future female partnersexual people.on one hand, or a surrogate mother in case of a male partner.In short we will discuss the various theoretical options thatThe latter case would allow the couple to have their ownare available. It is worthwhile to mention that although mostgenetic child.transsexual people will form heterosexual relationships after

transition, many will not, illustrating the well known fact thatsexual orientation and gender identity are quite different

Embryo bankingentities. Therefore, not all options are available for all trans-Embryo banking requires hormonal stimulation and oocytesexual people alike.retrieval (as for oocyte banking or IVF) and it also requiresspermatozoa from a male partner (or donor) with subsequent

Sperm banking in transsexual women (male-to-female freezing of the embryos. Embryo freezing is now a routinetranssexual patients) procedure in IVF and yields reasonably good results. Of courseIt is well known that feminizing hormonal therapy will induce it also would require a recipient uterus (female partner orhypospermatogenesis in transsexual women, and ultimately surrogate mother).will lead to azoospermia (Schulze, 1988; Lubbert et al., 1992).This azoospermia may be considered irreversible after some

Ovarian tissue bankingtime, and furthermore gender reassignment surgery withremoval of the testes obviously leads to irreversible sterility. Ovarian tissue banking probably has the most potential for the

future and is already being used for women who undergoThe only option, therefore, is to perform sperm preservationby freezing a number of semen samples, preferably prior to chemo- or radiotherapy for a malignant disease. Ovarian tissue

banking requires no hormonal stimulation nor IVF, and isstarting hormonal therapy. This banked spermatozoa can thenpossibly be used later to inseminate a female partner if the technically as easy as sperm freezing. Through means of a

laparoscopy ovarian tissue can be removed, and the ovariesquality is good, or else be used to perform IVF.In case of a future male partner the situation is the same as retain usable follicles even after hormonal therapy (Van den

Broecke et al., 2000), which implies that removal of ovarianwith homosexual men today, and there is little help availableexcept when an oocyte donor and surrogate mother are tissue can well be performed at the time of oophorectomy.

Ovarian tissue banking would also require donor spermato-involved. Since many transsexual women are, however, sexu-ally oriented towards women after transition (and therefore zoa and a recipient uterus of a future female partner or a

surrogate mother in case of a male partner. The problem ofidentify as lesbians), sperm banking should routinely beoffered to people considering hormonal and/or surgical gender ovarian tissue banking is not the freezing but the question of

what to do with the tissue after thawing. One has the optionreassignment treatment. Any man undergoing a treatment thatwill damage his reproductive potential (such as chemo- or to graft the ovarian tissue into the patient himself (Shaw et al.,

2000) (of course this is not an option for transsexual men), inradiotherapy for a malignancy) is now offered the opportunityto bank spermatozoa, and the transsexual woman should be another patient (leading to possible problems of immune

rejection) or in another animal (such as the mouse, but hereno exception to this.

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P.De Sutter

Benjamin, H. (1966) The transsexual phenomenon. The Julian Press Inc.may arise some serious ethical objections). In these threePublishers, New York.

scenarios follicular growth and ovulation should still be induced Boediono, A., Suzuki, T., Li, L.Y. et al. (1999) Offspring born from chimeras(Oktay and Karlikaya, 2000) and IVF would be needed to reconstructed from parthenogenetic and in vitro fertilized bovine embryos.

Mol. Reprod. Dev., 53, 159–170.obtain fertilization and pregnancy. As another possibility,Brewaeys, A., Ponjaert, I., Van Hall, E.V. et al. (1997) Donor insemination:in-vitro culture of the tissue fragments, with follicular growth child development and family functioning in lesbian mother families. Hum.

and oocyte maturation in vitro still seems to lead to poor Reprod., 12,1349–1359.Brothers, D. and Ford, W.C. (2000) Gender reassignment and assistedresults so far (Smitz and Cortvrindt, 1999) and intermediate

reproduction: An ethical analysis. Hum. Reprod., 15, 737–738.approaches are being explored, combining grafting andBryan, E.M. (1998) A spare or an individual? Cloning and the implications

in-vitro maturation (Liu et al., 2000). So, although ovarian of monozygotic twinning. Hum. Reprod. Update, 4, 812–815.tissue banking seems to be the option to choose, much research Chan, R.W., Raboy, B. and Patterson, C.J. (1998) Psychosocial adjustment

among children conceived via donor insemination by lesbian andwill still be needed to bring this in practice for transsexual men.heterosexual mothers. Child Dev., 69, 443–457.

Chen, C. (1986) Pregnancy after human oocyte cryopreservation. Lancet, i,884–886.

The future Cohen-Kettenis, P.T. and Gooren, L.J. (1999) Transsexualism: a review ofetiology, diagnosis and treatment. J. Psychosom. Res., 46, 315–333.

In the future there may be other asexual ways of procreation Fisk, N. (1973) Gender dysphoria syndrome (the how, what and why of theawaiting us. Since the birth of Dolly it has been shown to be disease). In Laub, D. and Gandy, P. (eds) Proceedings of the second

interdisciplinary symposium on gender dysphoria syndrome. Stanfordpossible to obtain an individual starting from an adult cellUniversity Press, Palo Alto, California. pp. 7–14.(Bryan, 1998; Solter, 1998; Wolf et al., 1998). Many other Hanscombe, G. (1983) The right to lesbian parenthood. J. Med. Ethics.,

animal species have already been cloned and theoretically the 9,133–135.Haraldsen, I.R. and Dahl, A.A. (2000) Symptom profiles of gender dysphorichuman species will probably not be difficult to clone either.

patients of transsexual type compared to patients with personality disordersAlthough cloning may offer great potential to medicine inand healthy adults. Acta Psychiatr. Scand., 102, 276–281.

general and may have many useful applications, reproductive Hodgen, G.D. (1988) Perspectives in human reproduction. Hum. Reprod., 3,573–576.cloning (reproducing a copy of a given individual) probably

Jones, H.W. (2000) Gender reassignment and assisted reproduction. Evaluationdoes not seem of interest (Jones and Cohen, 1999). Indeed,of multiple aspects. Hum. Reprod., 15, 987.

no two clones would be really identical and at best one Jones, H.W. and Cohen, J. (1999) IFFS Surveillance 98: Preface. Fertil.could obtain similarities such as the ones that exist between Steril., 71 (Suppl. 2), 5S-34S.

Lawrence, A.A., Shaffer, J.D., Snow, W.R. et al. (1996) Health Care Needsmonozygotic twins raised at different times and in differentof Transgendered Patients. J. Am. Med. Assoc., 276, 874.places. Although a remote possible application of reproductive

Levine, S.B., Brown, G., Coleman, E. et al. (1998) The standards of care forcloning would theoretically be the creation of chimeras from gender identity disorders. Int. J. Transgenderism, 2, 2, http://www.

symposion. com/ijt/ijtc0405.htmtwo different cloned embryos, so that an individual arisesLiu, J., Van der Elst, J., Van den Broecke, R. et al. (2000) Maturation ofconsisting of the genetic make-up of two different individuals

mouse primordial follicle by combination of grafting and in vitro culture.(Boediono et al., 1999), it is not to be expected that such a Biol. Reprod., 62, 1218–1223.strategy will readily be admissible to society. Lubbert, H., Leo-Rossberg, I. and Hammerstein, J. (1992) Effects of ethinyl

estradiol on semen quality and various hormonal parameters in a eugonadalmale. Fertil. Steril., 58, 603–608.

Oktay, K. and Karlikaya, G. (2000) Ovarian function after transplantation ofConclusion frozen, banked autologous ovarian tissue. N. Engl. J. Med., 342, 1919.

Pache, T.D., Chadha, S., Gooren, L.J. et al. (1991) Ovarian morphology inIn conclusion, several reproductive options to help transsexuallong-term androgen-treated female to male transsexuals. A human model

people fulfil their desire for a child are already technically for the study of polycystic ovarian syndrome? Histopathology, 19, 445–452.feasible, or will soon be available The medical world, legisla- Robertson, J.A. (1987) Procreative liberty, embryos, and collaborative

reproduction: a legal perspective. Women Health, 13, 179–194.tion and society at large will need time to accept the conceptSchenker, J.G. and Eisenberg, V.H. (1997) Ethical issues relating toof transsexual reproduction and allow treatment. We think, reproduction control and women’s health. Int. J. Gynaecol. Obstet., 58,

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treatment: morphology of Sertoli cells, Leydig cells and spermatogonialgender reassignment therapy, so that future treatment may bestem cells. Cell, Tissue Res., 251, 31–43.

possible if wanted. Experience with lesbian couples shows Shaw, J.M., Cox, S.L., Trounson, A.O. et al. (2000) Evaluation of the long-term function of cryopreserved ovarian grafts in the mouse, implicationsthat when new techniques are available, new treatment optionsfor human applications. Mol. Cell, Endocrinology, 161, 103–110.are sought and offered (Hodgen, 1988), and there is no

Smitz, J. and Cortvrindt, R. (1999) Oocyte in-vitro maturation and folliclereason why transsexual people should be refused these new culture: Current clinical achievements and future directions. Hum. Reprod.,

14 (Suppl. 1), 145–161.possibilities.Solter, D. (1998) Dolly is a clone – And no longer alone. Nature, 394, 315–316.Van den Broecke, R., Liu, J., Van der Elst, J. et al. (2000) Follicular

development in cryopreserved ovarian grafts stimulated with recombinantReferences versus urinary FSH. Hum. Reprod., 15 (Abstract Book 1), 90.American Psychiatric Association (1994) Diagnostic and Statistical Manual Wolf, D.P., Meng, L., Ely, J.J. et al. (1998) Recent progress in mammalian

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