# Préservation de la fertilité pour les personnes transgenres, non binaires et les personnes expansives de genre en France: évaluation globale des services et pratiques de soins de santé

Maxime Chaillot, Sophie Brouillet, Noémie Ranisavljevic, Bérengère Ducrocq, Anne Mayeur, Brigitte Keriven-Dessomme, Thomas Freour, Sylvie Morel, Arnaud Reignier

## ► To cite this version:

Maxime Chaillot, Sophie Brouillet, Noémie Ranisavljevic, Bérengère Ducrocq, Anne Mayeur, et al. Préservation de la fertilité pour les personnes transgenres, non binaires et les personnes expansives de genre en France: évaluation globale des services et pratiques de soins de santé. Journal of Gynecology Obstetrics and Human Reproduction, 2025, Journal of Gynecology Obstetrics and Human Reproduction, 54 (8), pp.103002. 10.1016/j.jogoh.2025.103002. hal-05368633v2

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Original Article

# Fertility preservation for transgender, non-binary, and gender-expansive individuals in France: A comprehensive assessment of healthcare services and practices

<figure><img src="image_3.png" /></figure>

Maxime Chaillot<sup>a,∗</sup> <sup> ID </sup>, Sophie Brouillet<sup>b</sup> <sup> ID </sup>, Noémie Ranisavljevic<sup>c</sup> <sup> ID </sup>, Bérengère Ducrocq<sup>d</sup> <sup> ID </sup>, Anne Mayeur<sup>e</sup> <sup> ID </sup>, Brigitte Keriven-Dessomme<sup>f</sup>, Thomas Freour<sup>a,g</sup> <sup> ID </sup>, Sylvie Morel<sup>h</sup>, Arnaud Reignier<sup>a,g</sup> <sup> ID </sup>

ARTICLE INFO

Keywords:

Assisted reproduction technology

Fertility preservation

Transidentity

Transgender

ABSTRACT

**Introduction:** Fertility preservation (FP) consultations are recommended before treatments that may affect fertility, including gender-affirming hormone therapy (GAHT). While some FP centers in France assist individuals undergoing gender transition, many transgender, non-binary, and gender-expansive individuals still choose not to pursue gamete cryopreservation. This study provides an overview of access to FP for transgender individuals in France in 2021.

**Materials and methods:** This descriptive observational study includes 47 French centers authorized to conduct FP activities. A total of 85.1 % (40/47) of these centers responded to an online questionnaire conducted between September 2022 and March 2023. The questionnaire addressed the activities of the centers in 2021, waiting times, methods of care for transgender, non-binary, and gender-expansive individuals, and training provided to healthcare professionals.

**Results and discussion:** In 2021, 29 centers reported performing FP cycles for transgender, non-binary, and gender-expansive individuals, with some showing specialized expertise. Significant differences were noted between oocyte and sperm cryopreservation. Waiting times for sperm freezing were acceptable, but oocyte freezing faced longer delays. Some centers provided professional training and communication activities to promote services. The findings highlight the need for improved regional coverage, shorter waiting times, and better communication to ensure equitable access to fertility care for all.

**Conclusion:** This study reveals disparities in access to and quality of FP services for transgender, non-binary, and gender-expansive individuals in France. Further evaluations are needed to understand the disparities between centers and, where possible, include all centers offering FP services in France.

Introduction

There has been growing visibility in recent years of the diverse identities and experiences within the transgender community, not only in France but also in many other countries. The estimated prevalence of

transgender individuals remains subject to underestimation due to inconsistencies in methodology and definitions. However, studies report a prevalence of 521 transgender women and 256 transgender men per 100,000 individuals [1].

A significant proportion of transgender, non-binary, and gender-

<footnote><sup>a</sup> Service de Médecine et Biologie de la Reproduction - gynécologie médicale, Hôpital Mère et Enfant, CHU Nantes, Nantes, France</footnote>

<footnote><sup>b</sup> Université de Montpellier, Inserm 1203 DEFE, Service de biologie de la reproduction-CECOS, CHU de Montpellier, Montpellier, France</footnote>

<footnote><sup>c</sup> Department of Reproductive Medicine, Montpellier University Hospital, University of Montpellier, Montpellier, France</footnote>

<footnote><sup>d</sup> CECOS, Institut de Biologie de la Reproduction, CHU Lille, Lille, France</footnote>

<footnote><sup>e</sup> Reproductive Biology Department, CECOS, Paris-Saclay University, Antoine-Béclère Hospital, APHP, Clamart, France</footnote>

<footnote><sup>f</sup> Service de Santé Publique, CHU Nantes, Nantes, France</footnote>

<footnote><sup>g</sup> Nantes Université, INSERM, Center for research in transplantation and translationnal Immunology, UMR 1064, 44000 Nantes, France</footnote>

<footnote><sup>h</sup> CENS, Nantes Université, Nantes, France</footnote>

<footnote>* Corresponding author at: Médecine et Biologie de la Reproduction, CHU de Nantes, 38 Boulevard Jean Monnet, 44093 Nantes Cedex 1, France.
E-mail address: maxime.chaillot@chu-nantes.fr (M. Chaillot).</footnote>
expansive individuals, similar to cisgender individuals, express a desire to start a family [2]. Many seek fertility preservation (FP) and/or assisted reproduction techniques (ART) to fulfill this goal.

In France, the 2021 bioethics law establishes and promotes universal access to FP, emphasizing its importance for individuals undergoing medical interventions, such as hormonal or surgical treatments linked to gender transition, that may impair fertility [3]. The law mandates that healthcare providers systematically inform individuals about FP when their fertility could be affected by a treatment or pathology. Consultations are arranged through streamlined processes in authorized facilities to facilitate timely FP procedures. This includes prioritizing cases where medical treatment is urgent, ensuring that FP can be performed efficiently and without unnecessary delays. While France has made significant strides with this legislation, barriers to equitable access persist. Comparative studies have highlighted substantial differences in healthcare access, legal frameworks, and societal acceptance across countries [4]. Gender-affirming hormone therapy (GAHT) does not inevitably result in infertility, but its prolonged use could significantly impact reproductive potential [5]. On the other hand, gonadectomy, which is sometimes considered as part of the process, results in permanent infertility. Thus, FP is a vital component of reproductive healthcare, enabling transgender and non-binary individuals to preserve the option of having genetically related children.

For transgender, non-binary, and gender-expansive individuals assigned female at birth (AFAB), there is a paucity of long-term follow-up studies evaluating the impact of gender-affirming treatments, such as testosterone, on gametes. Existing research points to changes in cortical and stromal ovarian tissue [5-7], with observations of induced polycystic ovarian morphology [8]. Nonetheless, oocyte cryopreservation remains a feasible FP option, even during gender-affirming treatments, provided there is a brief interruption to minimize thromboembolic risks. This approach ensures these individuals retain their potential to conceive using their own oocytes. Conversely, transgender, non-binary, and gender-expansive individuals assigned male at birth (AMAB) undergoing hormone therapy may experience reduced sperm production, which poses fertility challenges and sometimes raises concerns about the continuation of gender-affirming treatment [5]. Sperm cryopreservation emerges as an essential method for preserving reproductive potential, allowing sperm samples to be stored for later use in ART.

According to Coleman et al., who follow the World Professional Association for Transgender Health (WPATH) guidelines, all transgender individuals should be counseled on FP options before initiating any medical treatments that may impact fertility [4]. This counseling is crucial, as the desire for children may arise over time, whereas the initiation of GAHT is often a priority for many transgender adolescents and young adults. However, standardized protocols to support both patients and healthcare providers in this regard are lacking. The 2021 study of the CECOS network shows significant geographical disparities in access to FP services for transgender individuals, with a concentration of centers in major cities and marked disparities in waiting times for consultations and treatments [9]. Despite advancements in transgender healthcare in France, there remains a paucity of research and data on FP services for this specific population, with only a minority pursuing FP due to various factors, including a lack of counseling.

The most recent French guidelines from the Haute Autorité de Santé (HAS) [10] and the French Professional Association for Transgender Health (FPATH) [11] offer comprehensive guidance on gamete preservation and FP. However, they fall short of providing detailed procedures for access or care structures. Although literature on FP in transgender individuals remains limited, particularly at the national level, the growing body of recent publications indicates a rising interest in improving the management of fertility issues within this population.

This article aims to thoroughly analyze the current state of FP services for transgender, non-binary, and gender-expansive individuals in France, evaluate existing healthcare practices, and identify potential disparities. We conducted a nationwide survey, gathering data from all

registered FP facilities to shed light on the availability, accessibility, and inclusivity of these services.

## Materials and methods

A multicenter national survey was conducted between January and June 2023, utilizing data from 2021. In France, the practice of FP is regulated and subject to authorization. Directors of all 47 authorized FP centers were invited to participate via an online questionnaire distributed through SphinxOnline software, which adheres to General Data Protection Regulation (GDPR) standards. Among these centers, 35 were affiliated with public hospitals, while 12 operated in private settings. The questionnaire was developed collaboratively by reproductive health specialists from the French Professional Association for Transgender Health (FPATH) and was critically reviewed by two independent transgender individuals to ensure inclusivity and relevance. This study seeks to be inclusive, however, for the sake of consistency and clarity, the term "transgender individuals" is used while also encompassing non-binary and gender-expansive identities. This choice is not intended to erase these identities but rather to ensure terminological coherence throughout the text. Ethical approval was obtained from the Nantes Health Ethics Group (GNEDS). As the study did not involve patient data, Institutional Review Board (IRB) approval was deemed unnecessary.

The questionnaire consisted of 4 sections and included 40 questions (Data 1). The first section gathered information on respondent characteristics, including the center's public or private status, geographical location, number of clinicians and biologists dedicated to FP, and the volume of sperm freezing and oocyte vitrification cycles performed in 2021. The second section focused on FP services for transgender individuals AMAB. It investigated whether centers had provided consultations for this population, how requests were accommodated, and the conditions under which services were offered. Data were collected on the number of transgender individuals AMAB seen in consultations, the number who proceeded with sperm freezing in 2021, the time required to secure a consultation, and the interval between consultation and sperm freezing. The third section addressed FP services for transgender individuals AFAB. It collected data on the number of FP-related consultations, the number of oocyte freezing cycles performed, and the timelines for securing consultations and completing oocyte vitrification procedures in 2021. The final section examined the training received by center staff on gender-related matters, their participation in care networks dedicated to transgender health, and any challenges or feedback regarding the provision of care to transgender individuals.

The survey was distributed via email, with three follow-up reminders sent to maximize the response rate. The survey results were exported from Sphinx-IQ2 software (version 7.4.9) into Microsoft Excel for analysis using descriptive statistics. Each FP center provided one non-anonymous response. Data from this study are available upon reasonable request from the corresponding author.

## Results

Of the 47 French FP centers, 40 (85.1 %) responded to the questionnaire, with 77.5 % (31/40) affiliated with university hospitals. Most of the professionals who responded to this survey were biologists. All participating FP centers reported offering both sperm and oocyte freezing services. Of these, 78 % also perform ovarian tissue preservation, and 57 % perform sperm tissue preservation. Regional disparities should be considered in light of the population density of each region (Fig. 1).

The level of activity among FP centers varied widely. Centers with the highest activity (>200 sperm freezing cycles and/or >50 oocyte freezing cycles in 2021) were all situated in major urban areas. In contrast, centers with lower activity levels (<100 sperm freezing cycles and <10 oocyte freezing cycles) were primarily private facilities or public hospitals located in smaller cities or overseas territories. FP
<figure><img src="image_4.png" /><figcaption>**Fig. 1.** Geographical distribution of fertility preservation centers responding to the survey according to population density in each region based on data from Observatoire des Territoires, 2021. The first number indicated corresponds to the number of centers that responded to the survey, and the second number corresponds to the number of fertility preservation centers in the region.</figcaption></figure>

<figure><img src="image_5.png" /><figcaption>**Fig. 2.** Overall sperm freezing activity of French fertility preservation centers in 2021, and focus on transgender and non-binary individuals.</figcaption></figure>
<figure><img src="image_6.png" /><figcaption>Fig. 3. Overall oocyte vitrification activity of French fertility preservation centers in 2021, and focus on transgender and non-binary individuals.</figcaption></figure>

facilities were evenly distributed across France, with the exception of
the Centre region, where only one center responded.

FP in transgender, non-binary, and gender-expansive individuals AMAB
(Fig. 2)

Among the responding FP centers, 29 (72.5 %) reported performing FP cycles for transgender women in 2021. All requests from transgender women were accepted across these centers. These facilities were typically characterized by high FP activity. On average, 18 transgender women (range: 2–112) sought consultations for FP in 2021, with an average of 12.7 individuals (range: 1–83) proceeding with sperm freezing at each centers. Transgender individuals generally sought consultations at FP centers closest to their place of residence. Fifteen centers reported accommodating 2–6 patients residing outside their region. Among those who consulted an FP center, 75.6 % ultimately proceeded with sperm freezing. No significant correlation was observed between the overall activity levels of FP centers and the number of consultations or sperm freezing cycles performed for transgender women. For instance, three high-activity facilities in major metropolitan areas reported few or no consultations with transgender women, whereas some lower-activity centers reported accommodating a greater number of these patients. This substantial variability suggests the existence of specialized facilities and local referral networks. Sperm cryopreservation for transgender women accounted for 0–15 % of total sperm freezing activity across centers.

Of the 40 centers actively offering FP services, 23 (57.5 %) provided consultation appointments within 15 days, while an additional 8 centers (20 %) scheduled appointments within a month. Among the respondents, only 17 centers (42.5 %) had actively communicated the availability of FP services, primarily to healthcare professionals involved in transgender care (82.4 %). Fewer centers (41.2 %) communicated this information to LGBTQI+ associations.

FP of transgender, non-binary, and gender-expansive individuals AFAB
(Fig. 3)

Similarly, 29 FP centers (72.5 % of respondents) reported FP cycles for transgender individuals AFAB in 2021. Requests for FP services from this group were universally accepted by 21 centers (72.4 %). As with sperm freezing for transgender individuals AMAB, the level of activity in oocyte FP for transgender individuals varied significantly across facilities. On average, respondents reported receiving 13.7 transgender patients annually for information on oocyte freezing (range: 1–75).

A total of 6.3 oocyte vitrification cycles (range: 1–35) were performed across the 15 FP centers offering services to transgender individuals in 2021. Most transgender individuals sought consultation at the nearest FP center, with only 5 centers reporting that they had cared for patients from outside their region. Of the 328 transgender individuals who sought information about FP, only 94 (28.6 %) proceeded to freeze their oocytes. This proportion varied widely between centers, ranging from 8 % to 100 %. There appeared to be no correlation between the overall activity levels of FP centers and the number of consultations or oocyte vitrification cycles performed for transgender individuals. Notably, three centers accounted for 68 % of the total oocyte freezing cycles, highlighting the existence of referral centers. Some centers with high oocyte preservation activity also offered freezing for other medical indications (e.g., chemotherapy, endometriosis) but not for transgender-related indications. The time required to secure a consultation for FP exceeded one month in 18 centers (45 %), and oocyte vitrification was scheduled more than one month after the consultation in 57.5 % of cases (n = 23). Only 16 centers (40 %) had communicated the availability of this service, primarily to healthcare professionals involved in transgender individuals’ health (81.3 %), and less frequently to LGBTQI+ associations (43.8 %).

Taken together, these findings highlight significant disparities in access to and uptake of FP among transgender individuals across France.

Data collected from individual FP centers further illustrate these inequalities. In 2021, the average number of sperm cryopreservation
procedures per million inhabitants in the general population was 74.1 (min: 0.0; max: 214.5; median: 72.8), compared to only 3.4 among transgender individuals (min: 0.0; max: 11.6; median: 2.4). For oocyte vitrification, the average was 24.2 per million in the general population and just 1.0 among transgender individuals (min: 0.0; max: 5.8; median: 0.2).

Notably, several regions reported no FP activity at all for transgender individuals, despite the availability of services. While these numbers are based on self-reported data from FP centers and may not capture the full picture, they nevertheless suggest systemic barriers extending beyond individual facilities, raising serious concerns about equity in reproductive healthcare access nationwide.

## Information on care facilities

Among the respondents, 25 FP centers (62.5 %) were integrated into specific local medical networks dedicated to transgender patient care. Seven centers (17.5 %) had provided comprehensive training for all staff members, while 16 centers (40 %) had trained only part of their staff, primarily the medical team. A notable proportion of centers (42.5 %) had not implemented any awareness-raising activities for their staff regarding transgender healthcare needs.

## Difficulties in caring for transgender, non-binary, and gender-expansive individuals

Several centers reported challenges in providing care for transgender individuals, as noted in open comments. For instance, some centers highlighted difficulties in scheduling FP procedures when hormone treatment needed to be initiated urgently. Another challenge involved the care of minors, particularly with issues related to informed consent and ensuring that the information provided was fully understood. Additionally, some centers reported a lack of staff training, with the exception of referring practitioners. Regulatory uncertainty regarding the future use of frozen gametes in ART also emerged as a significant concern for both providers and patients.

## Discussion

This study provides a comprehensive assessment of FP services and practices for transgender individuals in France. The increasing number of publications reflects the medical community's commitment to improving care for transgender populations [11]. However, this study underscores persistent inequalities and significant heterogeneity in access to FP services.

### Territorial disparities

A key barrier identified in this study is access to FP services, driven by the uneven geographical distribution of FP centers across France. Some regions are critically underserved, with as few as two centers available (Fig. 1). This disparity poses a challenge, as many transgender individuals, particularly transgender men, prioritize initiating medical or surgical treatments promptly [12]. Expanding regional coverage could enhance access to FP, particularly as travel costs often deter eligible patients from pursuing these services [13].

Our study found that FP services for transgender individuals in France were mainly provided by a limited number of specialized centers, while many other facilities, despite significant FP activity, had not received any FP requests from transgender individuals. Although most respondents expressed goodwill in accepting transgender patients, the unequal distribution of FP services across the country raises concerns about whether existing centers truly meet the needs of transgender individuals in terms of accessibility, information, and care. This suggests that demand for FP services may be concentrated in certain centers with reputations for quality care, potentially facilitated by online directories of "safe" healthcare providers.

### Scheduling delay

The survey revealed notable disparities in wait times for accessing FP services, including information consultations and gamete freezing procedures. For example, delays of several weeks were reported for oocyte vitrification. These delays may stem from a shortage of specifically trained staff, though further research is needed to confirm this hypothesis. Additionally, a therapeutic window is often required before initiating FP procedures, particularly for individuals beginning hormonal therapy. After a few weeks of treatment cessation, FP can then be performed, and treatment can be resumed afterward. In such cases, transgender individuals may choose to forego FP to avoid delaying or stopping their medical transition. To address this issue, some medical teams now offer oocyte freezing after the initiation of testosterone therapy without requiring treatment interruption. However, limited data exist regarding the outcomes of this approach, particularly concerning gamete quality, quantity, and safety, highlighting the need for further studies [14]. In the case of adolescents, gamete preservation is not possible at the onset of puberty. In such cases, preservation of gonadal tissue may be considered. The use of GnRH agonists may also be an option, pending approval by a national multidisciplinary consultation meeting. Discontinuation of treatment is recommended in preparation for FP [15].

### Lack of information

Overall, despite widespread goodwill and local initiatives, the lack of accessible information on FP for transgender individuals remains a critical issue. This gap needs to be addressed not only by the specialized medical community but also by health authorities, with the aim of providing accurate information to both patients and non-specialized healthcare providers, such as general practitioners. Enhancing communication with transgender individuals and healthcare professionals is crucial to streamlining access to FP services [16,17].

The lack of sufficient training in transgender care among medical and paramedical staff is a significant concern. A recent study conducted in French university hospitals found that 60 % of practitioners rated their knowledge of transgender care as "low" [18]. It is well-established that transgender individuals often experience discomfort and discrimination in healthcare settings, with many encountering awkward or hostile interactions with healthcare professionals [19]. Therefore, it is essential for all staff involved in FP services to be sensitized to the specific needs of transgender individuals. This approach could ultimately increase the availability and utilization of FP services for this population.

Furthermore, initiatives aimed at combating discrimination against transgender people have been launched, with multidisciplinary consultations being introduced in some settings to simplify and improve care, including for GAHT and FP. Eustache et al. already mentioned in 2021 a lack of information on FP activity with transgender individuals [9]. Communication efforts with healthcare professionals and LGBTQI+ associations have also been made to improve the dissemination of information on FP for transgender individuals [20]. However, initial training for healthcare students is often still inadequate, highlighting the need for a more inclusive approach to patient care [21,22].

### Factors affecting preservation implementation

In this study, we also sought to explore the determinants that influence the decision to pursue FP among transgender individuals. The majority of transgender individuals seeking FP services are teenagers or young adults [9]. As a relatively young population, their immediate concerns often do not include parenthood, which may limit their perception of the importance of undergoing FP procedures. Many
transgender individuals may find it challenging to envision a future desire for parenthood [23,24]. Additionally, practical aspects of the FP process, such as vaginal ultrasound during egg retrieval or sperm collection via Masturbation, may act as barriers [25]. Minimizing invasive procedures is essential when working with this population, particularly as some may perceive certain interventions as “inherently misgendering”. As previously reported in the literature, the successful FP rate is generally higher for transgender individuals freezing sperm than for those freezing oocytes. Alpern et al. identified ovarian stimulation, associated examinations, and oocyte retrieval as significant obstacles for transgender individuals seeking oocyte cryopreservation [12]. However, the considerable variability in freezing rates observed across FP facilities in our study may also be related to differences in practices and referral protocols. For instance, some clinicians require a consultation at a dedicated FP center before initiating hormone treatment, which may result in lower freezing rates compared to centers that only see individuals who are already informed and actively seeking FP. Additionally, the prohibition of Reception of Oocytes from Partner (ROPA) and surrogacy in France may affect transgender individuals’ decisions to pursue FP and may lead some to resort to gamete donation to fulfill their desire for parenthood.

## Reuse uncertainties

A significant degree of heterogeneity is seen in the clinical use of frozen gametes in ART for transgender individuals. According to Baram et al., the clinical use of frozen gametes varies widely, from 10% to 82% in transgender women and from 0% to 17% in transgender men [23]. Legally, the 2021 French bioethics law does not explicitly authorize the use of frozen gametes following a change in gender on official documents, leaving patients in a state of considerable uncertainty regarding the scope and potential use of their preserved gametes. For example, a transgender man will only be able to access ART if he is in a couple with a cis or transgender woman. At the same time, a trans man who has conceived naturally will be recognized as the child's "mother". However, the same law does permit ART for female couples, which may pave the way for transgender women who have legally transitioned and preserved sperm to use their gametes in ART procedures. The initial experiences of some ART centers, along with the absence of opposition from health authorities and legal experts, could encourage other centers to follow suit, helping to normalize the use of frozen gametes for transgender individuals.

## Limitations

Our study did not examine patients' ages at the time of FP. It is important to emphasize that the age at which FP is performed is a critical factor influencing its effectiveness. For example, the number of oocytes frozen at a younger age is not always a reliable predictor of success. Further studies addressing this parameter are essential to optimize FP strategies and better inform patients about potential outcomes.

While this study provides an overview of FP practices for transgender individuals, our results date from 2021 and may be subject to interpretation. Examining their evolution over time and the impact of the 2021 French bioethics law on territorial disparities would provide valuable insights. Future research should focus on comparing male and female transgender individuals to better understand the specific barriers they face, which could inform targeted care strategies and policy improvements. In addition, they could seek to identify the reasons why certain centers do not carry out any preservation and look for possible causes of discrimination.

## Conclusion

In conclusion, this study highlights the current landscape of FP services for transgender, non-binary, and gender-expansive individuals in

France. Despite increased recognition of the importance of these services, significant disparities persist in access, regional distribution, and quality of care. While certain FP centers exhibit high levels of expertise and activity, others remain underdeveloped, often due to a lack of specialized training and awareness among healthcare providers. These findings underscore the urgent need for enhanced geographical coverage, reduced waiting times, and improved communication with both patients and healthcare professionals. Bridging these gaps is vital to achieving equitable reproductive care for all transgender, non-binary, and gender-expansive individuals in France

## Funding

This research was conducted without specific funding, relying on institutional resources to ensure its completion.

## Declaration of competing interest

The authors Chaillot et al. declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

## Acknowledgments

The authors wish to thank all fertility preservation centers that participated in this survey for their valuable contributions.

## Supplementary materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jogoh.2025.103002.

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