Transgender Fertility Preservation with guest Rick Zentler
Rick Zentler is joining me today to talk to us about transgender reproductive rights. He is 32 years old and lives in Austin, Texas area with his husband, Neil. He recently completed his MBA at San Jose State University, and he dreams of being a father and having a large family one day.
Rick is a transgender male and froze his eggs during transition prior to beginning hormone replacement therapy. He is joining me to talk about his egg freezing experience and to share what fertility clinics could do to better assist and guide trans patients. I look forward to sharing this interview with you with the hope that it can improve fertility care for transgender individuals.
Dr. Aimee: Welcome to the show. Thank you for being here to talk about transgender reproductive rights.
Rick Zentler: I’m really excited to be here, too, Dr. Aimee. It’s a topic that not a lot of people think much about, so it is so great to get a dialogue going and increase exposure.
Dr. Aimee: Can you share what your own journey was like as a transgender male deciding to freeze your eggs six years ago?
Rick Zentler: First things first, I had to save the money. I had just gotten my mastectomy the year prior, in 2014, which I paid about $8,000 out of pocket. Thankfully, I was in a position at the time to save most of my earnings because my previous husband was making a decent salary and could cover the majority of our costs of living.
Previously, I had hoped to donate some of my ovum to help fund my transition, but I got rejected by a couple of facilities and I started to get disappointed, so I gave up. There just really wasn’t a market for eggs of a trans man. They just looked at me genetically and rejected me. So, I decided to move forward with my own transition at that point. I consulted with my doctor at UCSF about the process, timeline, cost. I was told that it was going to be around $9,000, depending on the amount of medication that was required.
I was given the option of preserving either eggs or embryos. I went with the former. Dr. Mok-Lin, my doctor, was super understanding and she was very curious about my story. I felt like she was personally invested in helping me preserve my fertility. But I can’t say that the majority of the rest of the staff at UCSF were back then.
They were just working in their own little bubble. Even though they were based in San Francisco, they weren’t really primarily working with the LGBT community, so I got misgendered a lot. I just let it slide, there was no reason to get upset about it because I was there to have my procedure done and not really get feelings affirmed. I was there to get my eggs frozen. It was clinical, but I figured the majority of the staff’s empathy was going towards this is women and the heteronormative couples that were struggling with that very real and challenging aspect of infertility treatment, so I didn’t really fit into the typical narrative.
Mentally and emotionally, I was going through a lot. On the surface, it didn’t look like it, but I was super impatient to get my eggs out so I could get testosterone in. I’d read online about other trans men who had successfully halted their HRT and carried children fully to term, but you don’t want to gamble with that sort of thing. I wasn’t willing to assume that my own eggs would be viable if I began hormone treatment and then got back off of it. There wasn’t enough good information out there at the time to go off of. There still really isn’t. We need a lot more research in that area.
When it became time then for me to do the egg freezing, I spent a grueling couple of weeks on the medications. They have to be injected subcutaneously into your thigh every day, sometimes multiple times. It had me really high strung. I remember feeling like I was putting the wrong, the opposite hormones into my body that I wanted in my body, like I was going in the opposite direction of my transition. But I managed to power through it, even with all of the dysphoria that came with it. I wanted the result, so I focused on that result, and I got it done.
I do recall vividly going in for one doctor’s appointment toward the end of it for the intravaginal ultrasound and seeing on screen my inflated ovaries with the little follicles that had grown so much with the drugs. It was actually sort of a cute heartwarming moment, almost like getting to see your children. I wanted a picture. They didn’t offer me a picture, but I kind of wanted a picture to take home because they’re like my babies.
Retrieval day was a huge relief because then I was finally done with it. It went really smooth. They collected 28 follicles resulting in 36 eggs, and 34 of them survived the freeze. I was quite the proud papa, as it were.
I was told to take it easy for the next couple of weeks while I waited for my gonads to shrink, to avoid torsion and all that good stuff. Later that month I was on testosterone, and everything was great.
Dr. Aimee: Thank you for sharing. Over 30, it sounds like you could have been pretty uncomfortable after the egg retrieval as well. How was the physical recovery for you?
Rick Zentler: Recovery went pretty well. Compared to the other surgeries I’ve done, it was honestly a breeze in comparison. Three days and I was up and walking. I was ready to start my karate back up, but I didn’t want to do any jump kicks and end up with torsion, that would have been terrible. There was major pressure in the abdomen and just feeling bloated all the time, but it was worth it.
Dr. Aimee: I know that we were both interviewed for the same NBC article about egg freezing. One of the things that I shared was that oftentimes trans people have a harder time financially. Many don’t have family to lean on and they’re already paying for other procedures out of pocket. It’s heartbreaking. What do you want to see happen from a reproductive rights perspective for transgender people?
Rick Zentler: I feel like there’s this weird stigma floating around that the LGBT community is opting out of the gene pool or that they’ll just adopt. Transgender individuals should have the same access to having biological children as cis individuals. Reproductive ought to be a basic human right, we’re all equipped with the parts.
Hopefully, science will one day take us to the point where we can transplant functional ovaries and uterus into a trans woman and functional testicles into a trans man, but until then we have to make do with what we have at our disposal, which is the fertility preservation and surrogacy.
Some watching this might be thinking, “What do you mean have the same access? How can transgendered individuals have the same access to family building as cis individuals?” I’ll admit that’s a challenging question from a logistical standpoint. If you’re oversimplifying things, pregnancy is just putting a penis into a vagina.
Realistically, in this country, the United States, even the costs for a heteronormative couple having a baby are astronomical, especially if there are any complications or lack of insurance coverage. My brother and his wife actually just had their first kid this month, earlier. It’s a wonderful joy that has been brought to them, but they’re struggling with the bills.
I’d say don’t get it confused. The accessibility of becoming pregnant isn’t what we’re talking about here. We’re talking about the accessibility in finding and acquiring treatment and the costs therein. For transgender individuals, we’re facing a much greater obstacle because of the costs to transition.
Trans men might consider procedures such as a mastectomy, hysterectomy, ovariectomy, vaginectomy, to remove all of the unwanted parts they don’t want, and then consider phalloplasty and scrotoplasty to add the parts they do. Meanwhile, on the other side of the table, trans women might consider orchiectomy and penectomy to remove their unwanted parts that they don’t identify with and get breast augmentation or vaginoplasty to get what they do identify with.
This doesn’t even include surgeries that some trans folk might choose to do, like the facial, feminization or masculinization, the cost of hormone therapy, which is a recurring cost every time you have to get a prescription for testosterone or estrogen. There are other costs, too, that can be involved. Like seeing your therapist regularly for your mental health, getting a voice coach, maybe buying a new wardrobe. You have this new body, you got to flaunt it, right?
None of these are by any means a complete list, because some transgender individuals may opt for more, they may opt for a lot less. It’s really just how far do they want to go to be comfortable, but the common denominator is the same, it’s expensive. Then freezing eggs or sperm is expensive. Getting a surrogate is expensive. When you factor all of that in, there is a big inequity that I see between transgender and cis people who are wanting to do fertility preservation and have biological children.
Our lawmakers are continuing to stumble around trying to figure out what defines medical necessity, how does it apply to trans folk. We’re seeing some companies come and start to offer fertility preservation actually in their health plans, which is phenomenal, that’s great, that’s a trend that needs to continue. But ultimately, this shouldn’t be a difficult question; trans rights are human rights. Eventually we’ll get there, I suppose, but it’s frustrating in the meantime. We just have to keep pushing.
Dr. Aimee: We will keep pushing, together. I just want to touch on how you learned about egg freezing. You shared a little bit about your history growing up. Was it something that your doctor advised you on when you came out as trans?
Rick Zentler: Unfortunately, no. I have to admit that my own transitionary journey was very much self-pursued. I very much went the “I am informed and consent” model of things. I did as much as I had to for the laws. For instance, in the very beginning, I sought out a psychologist with a family counselor, and it was mostly to deal with the stress of coming out and managing all of my personal relationships with all of the people who knew me pre-transition.
My parents had a really hard time with it, so for a while I struggled with my relationship with them. Dr. Joe really helped me see from their perspective and how I could help educate them and get them on board and things like that. But I didn’t go there to help him help me figure out who I was. I knew I was trans. I showed up the first day and said, “I’m trans. How can you help me with my relationships?”
He was also extremely good about helping me set goals, writing them down, and creating lists about what I wanted to get out of my transition and how often I would be taking steps and evaluating them. One of those goals that was furthest out on the list was becoming a dad, so it’s exciting that I’m almost there now.
But after he gave me my letter of recommendation that I needed for my mastectomy, I went and I picked a doctor. I went with Dr. Crane because I saw his procedure did really well with preserving the lymph nodes, whereas other doctors weren’t as careful with their mastectomies. I did pay out of pocket for him, because he was completely out of network, but that’s what I chose to do.
UCSF was also my own choice. I didn’t have any coverage with my employer or my insurance or anything, but they looked like the right choice. There was no referral involved. When it came to testosterone, I went through Kaiser. They had me again see a psychologist, and he wrote me off as good, I signed my letter of consent and I got on testosterone.
All of the doctors that I’ve met with, I say, “Hey. I’m trans,” and they go, “That’s cool. How can we help you?” I say that I need this, that, or the other, and they say, “Cool. Jump through these hoops and we’re good to go,” and I’ve been good to go.
I did realize I was trans later in life, thankfully, so I was able to just be like, “I’m adult, I know what I want.” But we’re seeing a lot younger people now coming out as trans and they have to have their parents sign off on them or they haven’t really thought about strongly what they’re going to want when they’re 30, 40, 50, later, if they want to be parents and that sort of thing. This is why I keep saying that we need to see more proactivity on the behalf of all of the staff, whether they’re just a surgeon doing surgeries, whether they’re a fertility preservation specialist, whether they’re just a standard general practice. Everyone needs to be a little bit more educated.
Dr. Aimee: You brought up something about your experience that I just want to bring up again, about being misgendered and how that affected you. As a fertility doctor, I’m very sensitive about making sure that I just get it right every single time for every single patient. What kind of advice would you give to a patient to advocate for themselves if they find themselves in a similar situation as you were in, so that it doesn’t happen to other people?
Rick Zentler: That is a difficult question. It depends on every transgender person. Some of us don’t really speak up well for ourselves, or we feel nervous. These are professionals we’re around, this is their business, and we’re just patient, so it can be very hard to stand up for yourself.
I always feel like having an advocate by your side, if possible, is great. If a family member or a spouse or whatnot could accompany you to the appointments, sometimes it’s way easier for them to speak up and be like, “Actually, correcting you, my spouse would prefer to go by…,” just like that. Sometimes it’s just very helpful to have someone with the ball in your court so you don’t feel like you’re the only one bringing it up over and over, you feel like you’re a bother or a nuisance, and really it’s just you’re trying to get the care that you deserve both physically and mentally, emotionally.
Dr. Aimee: Thank you for that. You froze your eggs or your ovum six years ago. Now, looking back, how have things changed in the last six years, do you think, for transgender people who are going through this process?
Rick Zentler: Admittedly, it’s a little bit difficult for me to say, because I haven’t really been back in that space. I am going to be resuming it, next month we have an appointment to go for the next step. However, I do have friends who some of them are considering getting fertility preservation and others aren’t. I haven’t heard a lot about amazing experiences any of them had. I haven’t heard any terrible horror stories either, so that’s good.
I feel like there really hasn’t been sufficient progress in the field. When I go in for just doctor’s visits and whatnot, I will introduce myself as transgender and the doctors just have this kind of, “Okay,” response. It’s nice that it’s not taboo or whatever anymore, or weird and seen as abnormal. But they don’t ask the follow-up questions. You have to be extremely proactive about telling them what parts you do or don’t have. The last time I went in, someone tried to schedule me for a pap smear. I was like, “I told you I had a hysterectomy, there’s not much to check out down there anymore.”
It’s all about communication, honestly. There just needs to be more education on behalf of the staff that are treating transgender patients. There needs to be more communication on behalf of the transgender person, because, like I said, all of us are different, we all have different comforts in how far we’ve gone with transition, how far we intend to go with transition, the timing of the various aspects of transition. It really just requires a lot more dialogue on a subject that people, at least in this country, are very hesitant to talk about, they kind of feel like it’s private, even in a medical setting, that we shouldn’t talk about it, but it’s the exact opposite.
Dr. Aimee: It sounds like the changes that you want to see in the medical field are just better communication, more communication, and just talking about all of the things that you’ve gone through so that your doctor knows everything there is to know about you.
Rick Zentler: Right. It’s individual. Of course, all care is individualized to the patient. It has to be the same way with trans.
Dr. Aimee: I read really nice articles that you’ve been interviewed for. You were quoted as saying that it was very freeing to know that you had the ability to preserve eggs and then start taking testosterone. How did you find out about this option to preserve your fertility?
Rick Zentler: Actually, when I was growing up I did know a couple, they were my parents’ friends, that decided to have children pretty late in their mid-40s. They had to have IVF for their first kid in 2000, and they had to have a donor egg in 2004 for their second kid. I was a teenager at the time. Their struggles made me aware that there was this concept of reproductive assistance, that there were medical things that could be done to help people have a baby naturally themselves.
When I came out as trans to my parents in 2011, one of my mom’s biggest concerns was that I wasn’t going to be giving them any grandchildren. I had to explain to her that being transgender and being a parent weren’t mutually exclusive, you could do both, and that I did want kids, I just didn’t want to gestate them myself in my own body.
I consulted my friends, first and foremost, to ask them about their experience with IVF, what I could expect both financially and in the procedure. Then I hit the internet and did my research about prices. I ended up settling on UCSF just because of cost, proximity, and their quality of service.
Dr. Aimee: Was there anything that you wish you had known before you froze eggs as a transgender male?
Rick Zentler: Mostly future costs. I felt pretty informed going in. Dr. Mok-Lin, like I said, was great, she was an excellent resource, she was a great confidant. But really, the retrieval and freezing process are only half the story. The fertilizing, the implementation, the surrogacy, none of those were really discussed in much detail other than they’ll need to be done. Those are even more expensive.
On the other hand, I think it would have been a little overwhelming at the time. Back in 2015, I just really wanted to transition physically and realize my true self and have, like you said, that peace of mind that I could be a father later on when I was mentally and emotionally mature. It would have been a little overwhelming to be hit with that right at the beginning.
Dr. Aimee: What education do you think is still in need? It sounds like there could be more financial counseling. If you had your way to run a transgender fertility preservation clinic, what are the things that you would make sure were present in that type of clinic?
Rick Zentler: Like I said, the two need to go hand in hand. When you’re talking about fertility treatment, you also need to be talking about transition, and vice versa. Any discussion on transition should include fertility preservation, they should know that it’s an option.
The current reality where we are medically right now is that transitioning, depending on how far you go with SRS or gender affirming surgery as it’s more often referred to now, it renders the individual partially or fully infertile. Just like cis women shouldn’t have to give up their career to have children, a transgendered person shouldn’t have to give up or choose between their identity and having kids biologically.
Ironically, we have young women who get harassed all the time, “What if you want babies,” when they’re looking to get their tubes tied or whatever, and yet you see young transgender individuals who are going in and want to transition, and they really aren’t consulted or informed about their reproductive options. They just get right on the testosterone or the estrogen and then maybe their body is good, maybe it’s not.
I will say to an extent this might be self-inflicted. As I mentioned myself, I was extremely impatient to have my eggs on ice so I could start HRT. I tend to be a fairly introspective person, I don’t rashly jump to things, but not everyone who is looking to transition has a healthy home situation or a good support group to help them along and emotionally make the best decisions for themselves.
When you’re being misgendered on the daily, you hate your appearance, you’re suffering from dysphoria, it’s extremely hard to see anything beyond the short-term, especially having kids. You just want to be the gender you are, so you might do something that you later regret. I feel like the burden is shifted then to the doctors, to the therapists, to the medical professionals to put that conversation on the table and make sure that it gets discussed. It’s up to lawmakers, health care providers, and private institutions to make that care both accessible and affordable to people.
Dr. Aimee: One of the things that I know can impact transgender people is the financial burden of all the treatment that you go through. In your case, you started this process six years ago, knowing that you’d want to be a father pretty far out in the future. Can you just share a little bit more about the financial burden and your standpoint with regard to what you’re doing?
Rick Zentler: Yes. For me, UCSF actually included five years of storage with the procedure, which was a huge relief because, like you said, I knew I wasn’t going to be doing it for a while, at least until my 30s.
Dr. Aimee: So, you’re hoping to raise funds to cover some of your own costs. What do you need, and where can people go to help out?
Rick Zentler: As of right now, my partner and I are focusing on the next step of IVF, the fertilization and embryo cryopreservation. The cost estimate for that is $5,840. At present, we are still paying out of pocket. We’re planning to undergo that step in May or June 2021. That’s going to hit us quick, time always flies so fast.
I did start a GoFundMe to collect donations from friends, family, and interested parties. Every little bit helps tremendously. I can’t say how grateful I am to everyone who has helped so far. If anyone is interested, it can be accessed at www.gofundme.com/f/transivf. I’m sure you’ll put that link in your comment section for me, and it’s appreciated.
Dr. Aimee: Absolutely. If I had a room full of doctors, medical students, nurses, what advice would you have for them based on your experience about your journey to preserve your fertility?
Rick Zentler: Again, knowledge is power. For the most part, I think further education on what it means to be transgender, what it’s like to be transgender, and the services transgender folks need most would be extremely beneficial to those working in the fertility preservation field. What’s needed is more understanding and more empathy and respect for the individual needs of each trans person and their situation.
I didn’t get a lot of attention or particular care when I had my eggs frozen in 2015. I have a pretty thick skin, but making the process more trans-friendly will help more trans folk consider it as an option and preserve their genetic material to use and make them feel more comfortable, like they aren’t just an outsider in a cis person or heteronormative world. I think we can make them feel comfortable, welcome, celebrated, and even that fertility preservation can be as affirming as the rest of transition if done correctly.
Ideally, I would love to see transgender reproductive experts who specialize in providing this fertility preservation to transgender patients as a part of the regular staff at all facilities. Our society is becoming increasingly trans-accepting and more and more people are coming out as trans. More people than we thought were trans are trans, and they’re starting their journeys towards self-actualization, and this will necessarily include having biological children. It makes sense to have specialists who can more closely align with trans needs.
Dr. Aimee: How would that actually play out, what could I do today to make the experience more trans-friendly? I just want to make sure that I’m learning as much from you as possible as far as what I can do to make that experience better. I try to make every experience individualized and I want everyone to have the best experience. What are some tips that you would have for me specifically? Aside from having a doctor that is assigned to working with trans patients, what else could I do?
Rick Zentler: I think right there is a big key we’re hitting on. You care. You make a genuine effort. You are interested in having this dialogue. You are interested in individualizing the experience and opening your heart and your mind to learning more. That’s going to be the first step for anyone who wants to do this. You can’t just put us in a box, “Oh, this is another transgender person, we checkmark the box.” It has to be individualized.
I would say figuring out, asking the individual what they prefer their parts to be called, for instance. I know some people are perfectly happy still referring to it as a clitoris, but perhaps some trans men would prefer to have it be called a penis or a phallus, or what have you. Figuring out the language that makes that person the most comfortable and then using it consistently is phenomenal. That’s just a little thing that can be done, but it’s so important. It goes beyond just, “What pronouns do you want me to use?” When referring to someone’s body, they need to be referred to in the way that makes them comfortable.
Also, I would say just theory crafting a little bit. Ultimately, most are going to be there to be preserving it so they then go on hormone treatment, and they are thinking very shortsightedly, they just want to get it done so they can do what they need to do to realize themselves. Doing that theory crafting with them about, “Aren’t you looking forward to becoming a father, becoming a mother,” really connecting the experience.
We identify as male or female, but you can also identify as a mother or a father or a brother or an uncle, and those qualifiers are almost as important. If you’re really channeling the feelings of the transgender individual, you’re going to be saying, “Aren’t you looking forward to being a papa?” Like I said, I really wanted a picture of my eggs. It sounds crazy because they’re not a baby yet, but they will be a baby, and I kind of wish I had that silly little picture to put on my fridge so that I could look at it and smile and know that my future children are waiting, that I’m going to be a dad someday.
I really feel like there’s just a lot of little personal human touches, human elements that go into it beyond just the clinical, “Inject yourself with this. You can expect these changes with your body. Three days from here, you’re going to do that.” It works, and we do it, but it’s not the same. I imagine when people go in for infertility there’s always a lot of care and empathy that goes into it because they’re in a very sensitive, delicate situation where emotions are running really high, they’ve been trying to have a kid for a long time. It needs to be treated with that same level.
Dr. Aimee: It’s about the journey, it’s spiritual.
Rick Zentler: Absolutely.
Dr. Aimee: It’s about a baby. It’s not just about freezing an egg. I love all of the advice that you’ve given us. I hope everybody who cares for transgendered people listens to this interview and listens to all of the advice that you have for us and takes it to heart.
I know that not all clinics are welcoming to everybody. Obviously, we’re so lucky in the Bay Area that we’ve been trans-friendly for decades, but I know that it’s not the same way everywhere else. Hopefully, it’s going to be that way in the near future.
Rick, is there anything else that you would like to add today for us?
Rick Zentler: Only that I really appreciate sincerely your time, your interest, your willingness to use your platform to get my story out, to advocate on behalf of all the trans folk out there who are hoping to have their own families someday.
Dr. Aimee: I hope that you’ll update us with what happens with embryo creation and beyond.
Rick Zentler: I so look forward to sharing pictures of my babies.
Dr. Aimee: Thank you so much for being on the show. All the best to you and Neil. Thank you again.
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