Retrieving viable sperm from men with low fertility and from people who have used estrogen therapy for years has been a challenge, doctors say. A new, less invasive technique has promise.Claire always knew that she wanted to start a family. But as a transgender woman who just turned 41, she also knew it could be complicated.Claire and her partner discussed having a baby together and, if possible, they wanted to use her sperm and her partner’s egg. But Claire, who spoke on the condition of anonymity to protect her family’s privacy, had been on estrogen therapy for 18 years, and the chances that doctors would find any viable sperm were slim.At the same time, Claire was scheduled to have her gender confirmation surgery, a vaginoplasty. The procedure would remove her penis and testicles and create a functional vagina, permanently ending her body’s sperm production.Transgender women take medications to suppress testosterone production and increase estrogen, which tend to decrease sperm production and often shut it down entirely. But a new procedure called extended sperm search and microfreeze, or E.S.S.M., makes retrieving that sperm possible, unless sperm production has stopped altogether.Using E.S.S.M., Dr. Michael Werner, a urologist specializing in sexual and reproductive health, was able to find and freeze more than 200 of Claire’s viable sperm. Her procedure was the first known time that doctors had been able to retrieve viable sperm in a transgender woman after more than two years of hormone treatments.Dr. Arie Berkovitz, an obstetrician and gynecologist and a male fertility expert at Assuta Hospital in Rishon LeZion, Israel, created the E.S.S.M. technique in 2017 as a treatment for men with low sperm counts.Sperm production requires consistent testosterone production in the testicles — 40 million total per ejaculate is considered normal. E.S.S.M. does not increase sperm production. With E.S.S.M., doctors are able to find and freeze small amounts of sperm from the ejaculate without side effects; finding such samples can otherwise be difficult in people who have undergone extended hormone therapy. Previously, patients with low sperm counts or those thoughts to have no sperm at all had to undergo an invasive surgery in which sperm was removed through a needle inserted into the testicle. The process can be painful and can damage the testes.“I was doing it for peace of mind so that I could be confident that I had tried everything,” Claire said of the procedure. “When I received the call that not only were there sperm but that there were so many, it was both astonishing and overwhelming.”In E.S.S.M., the semen sample is divided into tiny droplets and scanned using a high-powered microscope for several hours. Any sperm that are found are individually placed in a specialized device called a SpermVD and cryopreserved. Over 90 percent of them survive the freeze-and-thaw process.Dr. Michael Werner, a urologist specializing in sexual and reproductive health, at Maze Health in Manhattan.Jackie Molloy for The New York TimesDr. Joshua Safer, executive director for the Center for Transgender Medicine and Surgery at the Mount Sinai Health System, said the surgery’s success was promising for transgender women who would like to start a family later in life.On Being Transgender in America‘Top Surgery’: Small studies suggest that breast removal surgery improves transgender teenagers’ well-being, but data is sparse. Some state leaders oppose such procedures for minors.In Montana: Transgender people born in the state will no longer be able to change the sex listed on their birth certificate under a new rule that is among the most restrictive in the country.Generational Shift: The number of young people who identify as transgender in the United States has nearly doubled in recent years, according to a new report.The Battle Over Gender Therapy: More teenagers than ever are seeking transitions, but the medical community is deeply divided about why — and what to do to help them.“My reaction is twofold: I’m surprised and impressed,” he said. Referring to the surgery, he added: “As an endocrinologist, we don’t know what the limits are.”Before her procedure, Claire went to a fertility clinic in Boston, at her doctor’s suggestion, to see if the bank could retrieve and store her sperm before her surgery. The clinic could not find any gametes, or sperm, in her ejaculate, even though she had stopped taking her hormones 10 months earlier.Her urologist in New York referred her to Maze Men’s Sexual Health, a fertility clinic and sperm bank led by Dr. Werner. By then, her vaginoplasty was just one day away, and rescheduling could take a long time, given the waiting list. E.S.S.M seemed like a long shot, so she was surprised at the result..css-1v2n82w{max-width:600px;width:calc(100% – 40px);margin-top:20px;margin-bottom:25px;height:auto;margin-left:auto;margin-right:auto;font-family:nyt-franklin;color:var(–color-content-secondary,#363636);}@media only screen and (max-width:480px){.css-1v2n82w{margin-left:20px;margin-right:20px;}}@media only screen and (min-width:1024px){.css-1v2n82w{width:600px;}}.css-161d8zr{width:40px;margin-bottom:18px;text-align:left;margin-left:0;color:var(–color-content-primary,#121212);border:1px solid var(–color-content-primary,#121212);}@media only screen and (max-width:480px){.css-161d8zr{width:30px;margin-bottom:15px;}}.css-tjtq43{line-height:25px;}@media only screen and (max-width:480px){.css-tjtq43{line-height:24px;}}.css-x1k33h{font-family:nyt-cheltenham;font-size:19px;font-weight:700;line-height:25px;}.css-1hvpcve{font-size:17px;font-weight:300;line-height:25px;}.css-1hvpcve em{font-style:italic;}.css-1hvpcve strong{font-weight:bold;}.css-1hvpcve a{font-weight:500;color:var(–color-content-secondary,#363636);}.css-1c013uz{margin-top:18px;margin-bottom:22px;}@media only screen and (max-width:480px){.css-1c013uz{font-size:14px;margin-top:15px;margin-bottom:20px;}}.css-1c013uz a{color:var(–color-signal-editorial,#326891);-webkit-text-decoration:underline;text-decoration:underline;font-weight:500;font-size:16px;}@media only screen and (max-width:480px){.css-1c013uz a{font-size:13px;}}.css-1c013uz a:hover{-webkit-text-decoration:none;text-decoration:none;}What we consider before using anonymous sources. Do the sources know the information? What’s their motivation for telling us? Have they proved reliable in the past? Can we corroborate the information? Even with these questions satisfied, The Times uses anonymous sources as a last resort. The reporter and at least one editor know the identity of the source.Learn more about our process.Dr. Eric K. Seaman, a urologist who specializes in male reproductive health in Millburn, N.J., said that Claire’s success was uncommon.“It’s a Hail Mary that they were able to find any sperm after 18 years of hormonal therapy,” he said.Claire, who lives in Massachusetts, is one of about 1.6 million people in the United States who identify as transgender. For transgender women who want to undergo genital surgery, E.S.S.M. may be an option to preserve sperm.Dr. Safer, who is also the former president of the United States Professional Association for Transgender Health, said he believed this technology could benefit many of his patients. Since starting the Mount Sinai Center for Transgender Medicine and Surgery in 2016, he has seen a surge in transgender people seeking hormone therapy and surgery. The center performs 800 to 900 gender-affirming surgeries each year, he said.“More and more people are feeling safer about identifying themselves as transgender and getting hormones and having medical interventions,” he said. “But in the gender-affirming care world, our clinics need to do a better job of getting kids to do fertility preservation before they’re getting on hormones.”But Dr. Seaman said he was concerned that there could be an increase in the miscarriage rate related to the use of E.S.S.M. The sperm that is recovered using the technique tends to be more fragile because of the extra time it takes to travel through the epididymis, part of the duct systems of the male reproductive organs, compared with surgical retrieval from the testicles, where the sperm and its DNA are more robust.Cryo-tanks are used for long-term storage of sperm samples at Maze Health. Jackie Molloy for The New York TimesThe treatment — and its potential drawbacks — do not apply only to transgender women. About 1 percent to 2 percent of men who are infertile, Dr. Seaman added, have severe male factor infertility, a condition in which no sperm is found in the semen; half of all infertile couples have male factor infertility, too. While there may be a higher chance of miscarriage for couples using sperm retrieved using E.S.S.M., the procedure is much less invasive than — and preferable to — having sperm surgically retrieved from the testes, Dr. Berkovitz said.“It’s an operation, and there are no invasive procedures without complications,” he said about surgical retrieval of sperm from the testes.Men with severe male factor infertility are already at a higher risk of causing pregnancies that result in miscarriage, he added, because sperm may be damaged as a result of the condition.As long as transgender women have normal sperm production, E.S.S.M. should not interfere with their producing a healthy baby, Dr. Berkovitz said.“In this case, she didn’t have low sperm count,” he said. “Genetically, her sperm was normal,” so her fertility would be preserved for future use.Doctors were able to freeze enough of Claire’s sperm for her to have 30 cycles of in vitro fertilization in the future.“It’s a second chance for transgender patients,” he said. “We can offer them fertility preservation without any pain or discomfort, and without an invasive procedure or operation.”Still, Dr. Werner encourages transgender young people to bank their sperm before any medical intervention to avoid the potential risks of fertility loss and leave their options open for the future.“Unfortunately, the vast majority of trans women who are transitioning aren’t given the option to bank their sperm, and once they’re put on hormones and have their testes surgically removed, their options have closed,” he said.He is now starting to see more transgender women coming to the clinic to bank their sperm.Claire said she also wished she had sought guidance sooner.“I’d encourage young people to bank their sperm,” she said. “I know I wish I’d done it earlier.”

Physicians are raising awareness of the reproductive toll that work stress, long hours, sleep deprivation and years of training can exact.From the start, Dr. Ariela Marshall, a hematologist at the Mayo Clinic in Minnesota, proceeded with the conviction that if she worked harder, longer and better, she would succeed. And she did: She graduated as high school valedictorian, attended an elite university and was accepted into a top medical school.But one achievement eluded her: having a baby. She had postponed getting pregnant until she was solidly established in her career, but when she finally decided to try to have children, at 34, she was surprised to find that she could not, even with fertility drugs. Dr. Marshall attributed it to having worked frequent night shifts, as well as to stress and lack of sleep, which can affect reproductive cycles.When she reached out to other female physicians to share her story, she learned that she was far from alone; many women in her line of work were also struggling with infertility or with carrying a baby to term.In fact, a 2016 survey of female physicians in the Journal of Women’s Health found that nearly one in four of those who had tried to have a baby had been diagnosed with infertility — almost double the rate of the general public.In 2020, Dr. Marshall and several colleagues published an article in the journal American Medicine calling for more fertility education and awareness among aspiring doctors, starting at the undergraduate level. Jenn Ackerman for The New York Times“For many physicians like me, everything is so planned,” Dr. Marshall said. “Many of us decide to wait until we’re done with our training and are financially independent to have kids, and that doesn’t happen until we’re in our mid to late 30s.”To raise awareness of the issue, Dr. Marshall helped to create an infertility task force with the American Medical Women’s Association. In June, the association held its first national physician fertility summit, with sessions on egg freezing, benefits and insurance coverage for fertility treatment, and infertility and mental health. The association plans to hold another summit next year.The high rate of infertility holds for female surgeons as well. A survey of 692 female surgeons, published in JAMA Surgery in July, found that 42 percent had suffered a pregnancy loss — more than twice the rate of the general population. Nearly half had experienced pregnancy complications.Like other female physicians, many surgeons delay pregnancy until after their residency, making them more susceptible to health problems and infertility issues.Often, doctors must navigate 10 years of medical school, residencies and fellowships. The average age for women to complete their medical training is 31, and most female physicians first give birth at 32, on average, according to a 2021 study. The median age for nonphysicians to give birth is 27.Through social media, Dr. Marshall connected with two other female physicians who also struggled with infertility, and last year they wrote about the issue in the journal Academic Medicine, calling for more fertility education and awareness among aspiring doctors, starting at the undergraduate level. They also proposed providing insurance coverage for, and access to, fertility assessment and management, and offering support for people undergoing fertility treatments. (In December, Dr. Marshall gave birth to a healthy baby boy after completing a successful I.V.F. cycle.)For a year, Dr. Arghavan Salles, 41, tried to freeze her eggs, but none were viable. Dr. Salles, an author of the article and a surgeon at Stanford, is also struggling with the expense of the procedure, which can cost up to $15,000 per attempt. She is looking into intrauterine insemination, which is more affordable but has a lower likelihood of success.In 2019, she wrote an essay in Time about having spent her most fertile years training to be a surgeon only to discover that it might be too late for her to have a baby. Afterward, many female physicians contacted her to say that they had also dealt with infertility.“They all felt so alone,” Dr. Salles said. “They had all gone through this roller coaster ride of dealing with infertility on their own, because people just don’t talk about it. We need to change the culture of med school and residencies. We have to do a better job of urging leaders in the field to say, ‘Please, go and take care of what you need to do.’”Dr. Arghavan Salles, a surgeon at Stanford, has written about how she spent her most fertile years in medical training and now struggles with few pregnancy options. Preston Gannaway for The New York TimesSleep deprivation, poor diet and lack of exercise — inherent to the demands of medical training and the medical profession — take a toll on women seeking to become pregnant.Even finding a partner can be a challenge, given the demanding work hours, including nights and weekends.“The problem is you have to spend a lot of time in the hospital and it’s very unpredictable,” Dr. Salles said. “One could look back and say, ‘I should have frozen eggs in my early 20s,’ but the technology wasn’t very good then. We see older women who are celebrities in the news having babies, and we think it will be fine, but it’s not. Now we’re all having this realization that we don’t have control over our lives.”Dr. Vineet Arora, dean of medical education at the University of Chicago Pritzker School of Medicine and another author of the paper, is weighing how she and other educators can best advise leaders in medicine to address these issues.“The thing that surprised me the most is that infertility is a silent struggle for many of these women, but when you see the data, you realize that it’s not uncommon,” said Dr. Arora, who underwent many I.V.F. cycles in her 40s and finally had her second child last March.She and Dr. Salles are analyzing data from a large study they conducted asking physicians and medical students about their experiences building families and accessing infertility treatments.Female residents who do manage to get pregnant must also contend with poor health outcomes; many go into early labor or experience miscarriages as a result of the long hours and stress of the job. Yet pregnant female residents are still expected to work 28-hour shifts, without sleeping. Dr. Arora and others would like to see that change.Dr. Roberta Gebhard, who is governance chair and former president of the American Medical Women’s Association, said the group is advocating for more accommodations for pregnant physicians, such as allowing women doctors to complete their heavy workloads at the beginning of their residency if they know they want to try to have a baby later on in their training.“We’re educating med students and pre-med students about fertility issues so that they are aware of them,” she said. “People say you can’t be a mom and a physician, and we’re telling you that you can, but you need to keep your options open. A lot of it isn’t just being able to get pregnant. Some of these women are so focused on their careers that they don’t get into a relationship.”For female physicians with babies, even finding the time and a private place to pump breast milk while on the job can be a challenge. Dr. Gebhard said that one doctor who asked for time to pump was instructed to go behind a potted plant in a public area to do so.She’s optimistic that things will start to change in the near future, as more than 50 percent of all medical school students are now women, although there are still more male physicians than women.Dr. Racquel Carranza-Chahal, an OB-GYN in Tucson, Ariz. “When I became a resident, someone told me that I needed to divorce my husband and lose custody of my child if I wanted a fellowship,” she said.Kristen Zeis for The New York TimesDr. Racquel Carranza-Chahal, 30, recently completed her OB-GYN residency and is now in private practice in Tucson, Ariz. She has a son, to whom she gave birth while in medical school, and a daughter.“When I became a resident, someone told me that I needed to divorce my husband and lose custody of my child if I wanted a fellowship,” Dr. Carranza-Chahal said.The day she spoke, she was on-call and had just completed her second 24-hour shift in seven days while eight and a half months pregnant with her second child.In 2019, she founded a nonprofit called Mothers in Medicine, which she hopes will increase visibility and community outreach for female physicians who are pregnant or are mothers.“I want moms in training to know that they should take up space, that they do belong and that there are resources at their disposal, including legal ones,” Dr. Carranza-Chahal said. “A lot of residents end up delivering early and having complications. One day I’ll change that.”