ASRM issues practical guidance for gender-diverse reproductive care

Clinical takeaway: Before gender-affirming hormone therapy or surgery, counsel patients about potential effects on fertility and available preservation options. Base contraception, screening, and reproductive care on the patient’s anatomy, treatment history, and goals—not gender identity alone.

The American Society for Reproductive Medicine (ASRM) has released a new committee opinion outlining comprehensive medical, surgical, gynecologic, mental health, and reproductive care for transgender and gender-diverse patients. The opinion arrives amid a rapidly shifting political and legal landscape: as of August 14, 2026, 27 states had enacted laws or policies limiting youth access to gender-affirming care, affecting half of U.S. transgender youth ages 13 to 17, according to KFF’s policy tracker.

ASRM recommends individualized, shared decision-making before hormone therapy, including discussion of expected effects, risks, adverse effects, and limited long-term evidence. No hormonal medication is FDA approved specifically for gender affirmation.

For peripubertal adolescents, ASRM says that gonadotropin-releasing hormone agonists may be offered beginning at Tanner stage 2. Because of potential bone loss, these agents generally should not remain the sole therapy for more than a few years; progestins may be used for menstrual suppression when puberty blockers are inaccessible or unsuitable.

Testosterone may be given intramuscularly, subcutaneously, or transdermally. Monitor CBC, metabolic parameters, testosterone, and estradiol—initially as often as every 3 months, then annually after dose stabilization—and address hematocrit above 50% by reducing the dose, considering transdermal therapy, evaluating other causes, or using serial blood donation.

Testosterone is not contraception. Patients with pregnancy potential should receive contraceptive counseling, and persistent bleeding despite male-range testosterone and adequate estrogen suppression warrants evaluation; levonorgestrel IUDs, systemic progestins, or combined oral contraceptives may help control bleeding.

For estrogen-based therapy, ASRM advises combining estradiol with an antiandrogen when testosterone suppression is desired. Avoid conjugated equine estrogen and ethinyl estradiol because of thromboembolic risk, and favor transdermal estradiol for patients who smoke or have cardiovascular risk factors.

Avoid spironolactone in renal insufficiency and monitor potassium and creatinine during treatment. Routine thrombophilia testing should be limited to patients with a personal or family history of venous thromboembolism, while progestogen use remains controversial because benefits are unproven and prolonged exposure may cause harm.

Clinicians should inventory retained organs and follow corresponding cancer-screening guidance. Gender-neutral questions, alternatives such as transabdominal ultrasonography or examination under anesthesia, and mental health consultation focused on support (not gatekeeping) can reduce dysphoria and barriers to care.

As the committee emphasizes, clinicians should view “affirmation as a flexible, continuous process, rather than a ‘one and done’ event.”

Source: Practice Committee of the American Society for Reproductive Medicine. (2026 Aug) Fertil Steril. Transgender and Gender-Diverse Care: A Committee Opinion