Advancing Equitable Oncofertility Care for Transgender and Gender-Diverse Patients

Transgender and gender-diverse (TGD) patients with cancer face unique and intersecting challenges related to fertility preservation. Although professional societies recommend early fertility counseling for both patients with cancer and individuals undergoing gender-affirming treatment, evidence specifically addressing oncofertility in TGD populations remains limited. Gender-affirming hormone therapy may affect gonadal function and gametogenesis, while interruption of hormone therapy for fertility preservation may exacerbate gender dysphoria. Fertility preservation options include oocyte, embryo, sperm, ovarian tissue, and testicular tissue cryopreservation, with selection dependent on reproductive anatomy, pubertal status, prior treatment, and oncologic considerations. TGD patients also face substantial barriers to fertility preservation, including cost, inadequate counseling, insufficient provider expertise, discrimination or bias, and lack of access to fertility care. This narrative review examines current evidence regarding fertility and fertility preservation in TGD patients, with particular attention to patients with cancer, and identifies critical gaps in counseling, clinical practice, research, and policy. Improving care will require early and individualized counseling, multidisciplinary collaboration, equitable access to these services, longitudinal research addressing reproductive outcomes in TGD cancer survivors, and the creation of inclusive clinical environments that support patients throughout fertility preservation and cancer care.