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There are some medical conditions and treatments that can compromise fertility, gender affirming hormones are one example. Often transgender and non-binary people have struggled for so long and endured such long waiting lists that the idea of further delays, while fertility preservation options are considered, can seem too exhausting. In reality, the question of whether or not they will one day want to have children, can seem somewhat abstract, particularly as it only truly becomes an issue when they are about to begin their long-awaited medical transition.

So focused are they on their need to course correct their situation by starting hormone therapies, that the longer-term implications on their own fertility, can get side tracked. When asked, many people genuinely feel that they will never want children, or they rationalise their situation with the thought that they will simply adopt when the time comes.

But, as a GP who has seen countless patients suffer as a result of being unable to conceive, I firmly believe that it’s vital to keep the option open for people to have their own biological children later in life, even if they decide not to do so.

What is involved?

For those who are assigned male at birth, it is a very simple procedure. Samples of ejaculate are stored in special conditions so that if that person ever wishes to create a biological child in the future, the option is there. When the time comes, the sperm is mixed with human eggs to create an embryo which can be transplanted into a womb to create a pregnancy.

For those who are assigned female at birth, the procedure is more difficult as the ovaries need to be pushed through a heavy hormonal cycle and then the eggs are removed from the ovaries with a mini surgical procedure. These harvested eggs can then be frozen and defrosted later to be mixed with sperm.

Pregnancy is not guaranteed with either of these procedures, but it is the best option available to anyone who wishes to have a chance of conceiving their own biological children later in life. The best time to undertake storage is before any medical or surgical intervention.

GenderGP reviewed 616 patients between the ages of 12 and 40 who were counselled about fertility conservation. This data will be presented at the WPATH in Buenos Aires in November 2018. As well as direct communication, the 616 patients were also sent detailed literature about gamete (sperm or egg) harvesting, storage and eventual usage.

Despite this, the uptake for gamete storage was disappointingly low.

  • 558 patients (90.4%) did not proceed with gamete storage
  • Only 58 patients (9.6%) patients proceeded with gamete storage
  • Of these 58 patients, all were assigned male at birth and banked sperm
  • No patient proceeded with egg storage

Aside from the desperation to start treatment, why is such a relatively straightforward procedure not taken up more often? If we have a look at the literature and guidance of fertility preservation on the NHS, it becomes more clear. GenderGP has reviewed the NHS guidance to see what patients should ask for should they be interested in fertility preservation and where should they go for the procedure but the answer is inconclusive.

NHS funding processes and waiting times for adult service users

‘Referral to specialist in reproductive medicine for advice and information about reproductive options such as cryogenic gamete storage and mechanical sperm retrieval and egg retrieval. Provision of storage of gametes and assisted fertility services should be offered in accordance with existing local policy.’

‘Before starting either, however, it is important to explore implications for fertility. This might include discussion of gamete storage. The GP is usually best placed to advise on local availability of gamete storage services.’

Interim NHS England Gender Dysphoria Protocol and Guideline

‘Full discussion of fertility issues, including the possibility of gamete storage, should precede endocrine treatment.’

Good practice guidelines for the assessment and treatment of adults with gender dysphoria 

‘If a person seeks advice on storage of gametes then they should be put in touch with a fertility centre offering licensed treatment. A list of centres in the UK can be found at the Human Fertilisation and Embryology Authority’s website (www.hfea.gov.uk)’

According to the HFEA website:

‘If you think you would like biological children at some point and you haven’t started medical treatment or had surgery, you may wish to preserve your fertility by having your sperm, eggs or embryos frozen and stored for later use in fertility treatment.’

In response to the simple question: ‘Can I have fertility preservation treatment on the NHS?’ the HFEA provides the following answer:

‘This is not straightforward to answer, and is subject to change and may depend on where you live. Funding for storing your eggs, sperm or embryos before having medical treatment for gender dysphoria varies depending on where you live.’

So what do I do now?

It seems that while there are references to gamete storage across the board, indicating that the importance of the procedure is recognised, access to treatment depends on where you live. Some areas will have clear policies like this one from Birmingham CrossCity Clinical Commissioning Group. People living in this locality will ask their GP to make an ‘Individual Funding Request’ for treatment and then, as stated, ‘The Individual Funding Request (IFR) team will take the policy into account when making decisions on an individual basis.’

Other geographical areas may or may not have such clearly defined policies, but if there isn’t a policy in place, then patients and GPs should request that  steps are taken to put a fair policy in place.

Practically speaking, those interested should ask their GP to apply for funding from their local fund-holding body. This will be the CCG in England, or the equivalent in Wales, Ireland or Scotland. The funding application will be looked at and then considered. If successful, treatment can be accessed. People do not have to have been seen by or be referred by a GOIC, so the best advice is to get this all in place while waiting for the NHS GIC appointment to come through.

Given the struggles that so many transgender and non binary people face to get the treatment they need, it is entirely understandable that the idea of adding this extra battle to an already overwhelming list, can be too much. But the truth is that, while it may take time, you will win your battle for acceptance. If you feel there may be a possibility that children could feature in your future, taking these steps could be the best decision you ever made.

If you are a trans or non binary person looking for support with access to fertility preservation, if you are looking for psychological support or if you need help with any other aspect of your medical transition, please get in touch: doctor@gendergp.co.uk

 

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