From Transition to Reproduction: A Narrative Review of Evolving Evidence in Transgender Obstetrics and Gynecology

Transgender and gender-diverse (TGD) people assigned female at birth (AFAB) increasingly seek reproductive and gynecologic care, yet evidence and clinical pathways remain variable across health systems, including in Europe.

The objective of this study was to synthesize evidence on fertility, pregnancy, gynecologic care, and access to care in TGD populations and to highlight practical implications for gender-affirming clinical practice, with attention to European settings.

A narrative review supported by a structured PubMed/MEDLINE search (January 1, 2014-May 31, 2025). Two reviewers screened 146 titles/abstracts; 58 full texts were assessed; and 31 publications were included. Nine primary studies reported quantitative pregnancy and/or assisted reproduction outcomes after prior testosterone exposure in AFAB TGD individuals.

Available data, largely small retrospective cohorts and case series, suggest that pregnancy and assisted reproduction are feasible after prior testosterone exposure, typically after temporary cessation. In studies with cisgender comparators, oocyte yield and embryology metrics appeared broadly comparable, but evidence remains heterogeneous and underpowered for robust safety conclusions. Survey-based studies indicate that more than half of pregnancies may be unintended. Barriers to fertility preservation (FP) and preventive gynecologic care include financial and structural constraints, limited provider training, and avoidance of pelvic examinations and cervical cancer screening.

Reproductive counseling, FP, contraception, and organ-based screening should be integrated into gender-affirming pathways using trauma-informed, patient-centered communication. Prospective multicenter studies and standardized outcome reporting are needed to better define safety, effectiveness, and equity of care.