Fertility preservation is a process aimed at preserving the ability to have biological children and can suit people who are interested in becoming parents in the future but have circumstances that may hurt their chances to do so, such as age and medical procedures (such as taking hormones for medical transition). As part of fertility preservation, eggs, sperm, or fetuses are frozen and stored at designated centers, for use in future pregnancies.
Fertility Preservation in the Trans Community
Medical transition procedures, such as surgeries and hormonal treatment, can have the potential to affect fertility in different ways. As of current research, there are hormonal treatments for gender affirmation that have higher chances of affecting fertility in the short and long term:
Fertility Preservation in AMAB People
Studies show that hormonal treatment including adding estrogen and blocking testosterone significantly affects testicle structure and sperm indicators. It is known that long-term exposure to this hormonal treatment can cause azoospermia, but the effects of stopping hormonal treatment on sperm quality are unknown.
Fertility Preservation in AFAB People
As of today, there is a lack of studies about the effects of testosterone supplementation on the reproductive system. It is known that taking male hormones can delay or stop ovulation and menstruation, but it is unproven whether these changes are reversible or not.
Therefore, for those who are interested in being biological parents, it is recommended to consider going through fertility preservation processes before beginning hormonal treatment.
The policy in Israel regarding fertility preservation in people on the trans spectrum is not officially regulated, so oftentimes people from the community fall between the different criteria, which can pose roadblocks on the path to fertility preservation. These roadblocks can include meeting medical criteria that not all people meet, the ability to finance procedures that are not in the healthcare basket, bureaucratic struggles with HMOs and long persuasion campaigns, and more.
The decision to preserve fertility or not depends on a variety of personal considerations, and it is a question that concerns many on the trans spectrum. Because of the lack of information, the recommendation is to consider the currently available information wisely and consider the importance of being a biological parent to you. Nobody can force you either way, and you should not be pressured to make a decision that doesn’t suit you.
Types of Fertility Preservation
Sperm Freezing
This is a process where seminal fluid is preserved by freezing it. This process can be suitable for those who were assigned male at birth and were born with male sex organs (penis and testicles). The seminal fluid preservation is done at sperm banks. Most sperm banks in Israel are in hospitals or private clinics. You can choose where to do the freezing process, and there is no obligation to go to a specific clinic. For people on the trans spectrum, the process can be funded by some HMOs at public sperm banks, the number of portions and years of funding can change according to HMO policy.
The freezing process includes giving a seminal fluid sample in a testing cup, and after giving the sample – filling out and signing documents. The freezing is usually done for a year, after which you can choose to continue the freezing. If you are not interested in continuing to freeze the sperm, the bank is required to submit a request to the Ministry of Health to defrost the sperm and remove it from use. The cost of sperm freezing ranges from 700-1000 NIS for one portion (the price varies between banks; a portion means one sample).
For those interested in sperm preservation, it is best to begin the fertility preservation process before starting hormonal treatment. If that is not possible, you need to stop taking hormones for at least three months to go through at least one sperm production cycle.
To begin the sperm freezing process, make an appointment with a fertility doctor. Bring the following lab results to the appointment (which check for diseases transmitted by sexual contact):
- HBsAg, HBsAb, Anti HCV
- VDRL
- HIV
Egg Freezing
It is possible to undergo egg retrieval and freezing at any hospital that has an IVF department, but it is important to note that Ichilov and Wolfson have professionals who specialize in fertility preservation for the trans community. It is recommended to undergo the egg-freezing process before starting hormonal treatment.
This is a surgical procedure where eggs are retrieved from the ovaries and are then frozen at the IVF department. The frozen eggs are not fertilized, and they will need to have medical actions done such as in-vitro fertilization (IVF) or ICSI.
Usually, the freezing is done for 5 years, after which you will need to discuss continuing storage with the clinic. Continuing storage will involve further payment.
Because this is a surgical procedure, the cost of doing the process privately is higher as it requires an operating room, anesthesia team, recovery nurse, and more. The cost varies between clinics and generally ranges between 4500-7000 NIS for one round of retrieval (not including the cost of the medications themselves which can range between 100-1000 NIS). Each round can produce 0-20 eggs and sometimes even more (depending on how the body responds to the hormones and the specific protocol used).
The process of egg freezing is more complex due to it being a surgical procedure. To do the retrieval, the eggs need to be of optimal size and condition so that they mature inside the follicles. To produce this optimal condition, it is necessary to inject hormones to increase the production of follicles in the ovaries. This process is called ovulation induction, and it will usually take between 2-6 weeks. Because the follicles are being artificially grown with hormones, it is necessary to track their growth closely – to make sure they are growing correctly, to confirm the amount, and to make sure not to miss the ovulation time. Therefore, every few days a blood test and ultrasound are performed (usually done internally and not on the stomach to determine the size and number of follicles more exactly, but it is not a requirement, and you can request to do it on the stomach). When the follicles reach the right size (usually around 18-20mm), you will receive an injection to synchronize the ovulation time.
The procedure itself is performed at the IVF department, usually under partial or general anesthesia, and usually will be scheduled for the day of ovulation. The procedure requires staying at the clinic for several hours afterward for recovery. The procedure is called retrieval because, with the use of a medical device, eggs are retrieved from the follicles which are then sent to a lab located near the operating room. The lab then bursts the follicles and checks which eggs are mature and in good condition, which are then frozen. It is possible to perform in-vitro fertilization (IVF), a process in which eggs are fertilized with sperm to make fetuses and then freeze the fetuses. The procedure itself usually takes 10-45 minutes.
To begin the egg-freezing process, the following tests are necessary:
- Blood count
- Glucose
- Clotting functions (PT, PTT)
- Kidney functions (BUN, CREAT)
- Antibodies (RUBELLA, TOXOPLASMOSIS, VARICELLA, CMV)
- PAP smear
- Breast examination
- Genetic screening
- Above the age of 40: ECG
Fertility Preservation Funding by Health Management Organizations (HMOs)
As of 2023, the subject of fertility preservation for people on the trans spectrum is controversial. Some claim that it is not included in the criteria for fertility preservation funding in the healthcare basket, while others claim it is. As of now, the HMOs are not required to fund it (Form 17 is required), but most have internal policies regarding the subject and in recent years the number of cases where HMOs fund the procedures if it proven to be medically necessary has risen. Additionally, some of the HMOs have specific guidelines for people on the trans spectrum.
It is always worthwhile to consult with your primary care doctor. You can request letters from an endocrinologist and a fertility doctor explaining the importance of fertility preservation due to hormonal treatments. It is important to note that funding is not always approved, and often approval will be given for a limited time or a limited number of rounds. Additionally, to avoid excess payments, make sure that the number of fertility preservation rounds that were approved aligns with the protocol used at the fertility clinic.
If the HMO doesn’t approve funding, you can submit a request for fertility preservation funding for the trans population on the Israel LGBT Association website.
HMO Procedures Regarding Fertility Preservation
Note that not all HMOs state that the service is available for those undergoing medical transition
Maccabi
Clalit
Leumit
- Egg preservation
- Ovarian tissue preservation
- Sperm freezing
Meuhedet
Clinics Offering Designated Fertility Preservation for the Trans Spectrum
Ichilov – Gender Clinic for Fertility Preservation, designated for fertility preservation for the trans population and provides services to minors on the trans spectrum as well.
- Sorasky building, Wing G, 3rd floor
- Phone – 03-6925606
- Email – hadaram@tlvmc.gov.il
Meir – LGBT Gynecology Clinic
- Outpatient clinics building, 1st floor, “Women’s Clinic”
- Phone – 09-7471666/2104
- Email – galcwork@gmail.com
Wolfson – Keshet Clinic
- Appointment scheduling – 03-5028111
- Whatsapp – 052-7241043
- Email – zimuntorim@wmc.co.il
Sheba – Fertility Preservation
There are additional clinics around the country that offer fertility preservation but do not have services accommodated to the trans spectrum.
For Further Reading
- Information about fertility preservation on the LGBT Association website
- Interview with Dr. Hadar Amir-Levy, fertility specialist, Ichilov Hospital.
- WPATH Standard of Care 8 (translated chapters on Maayan website)