smiling spermatozoids

ESSM: A New Fertility Option for Transgender Women?


  • Transgender women often struggle with fertility issues as a result of long-term hormonal therapies.
  • Fertility options for transgender women include “natural” conception, sperm cryopreservation, and microsurgical testicular sperm extraction (microTESE).
  • The extended sperm search and microfreeze (ESSM) procedure allows providers to find and preserve sperm in people with low sperm counts who were unsuccessful with other retrieval methods. 
  • The ESSM procedure is efficient and less invasive than microTESE.

Transgender women may have a better chance at having children, thanks to a procedure recently developed for men with low sperm counts. The extended sperm search and microfreeze (ESSM) technique is advanced, efficient, and less invasive than traditional sperm collection and preservation methods.


Transgender people who undergo gender-affirming care often face infertility. The extended sperm search & microfreeze (ESSM) is a novel technique that helps providers find and freeze sperm in people with low sperm counts. ESSM has emerged as a potential option for transgender women hoping to have children. 

Fertility Challenges for Transgender Women

Transgender women receiving gender-affirming medical or surgical therapies are at risk for infertility. This is disheartening, as some research shows that transgender women report wanting to become parents at the same rate as other LGBTQIA+ people.

Long-term hormonal therapy makes it challenging to retrieve viable sperm from transgender women. Medication that suppresses testosterone and increases estrogen can decrease or even cease sperm production. Some transgender women have their testicles removed, which makes sperm retrieval impossible. 

Research suggests that some transgender women may be able to regain sperm production after pausing hormonal therapy, but this is not guaranteed. What’s more, pausing gender-affirming care can have a devastating impact on someone’s mental and emotional well-being. 

Fertility Options for Transgender Women

Surveys confirm that the vast majority of transgender people believe fertility counseling should be provided prior to beginning gender-affirming care. Those who have undergone long-term hormone therapy or who have their testicles removed have limited options for having children. Accessing fertility options early on provides transgender people with more options for having children in the future.

Fertility options for transgender women currently include:

  • “Natural” conception. If a transgender woman still produces sperm and has a partner with a uterus, they may be able to conceive through sex. However, this depends on a number of factors, including sperm count and motility. Natural conception typically requires pausing all hormonal therapies.
  • Sperm cryopreservation. Transgender women can freeze and store their sperm using sperm cryopreservation so they won’t need to pause hormonal treatment if they wish to have children. An estimated three percent of transgender adolescents use fertility preservation before beginning gender-affirming therapies. This is also a popular fertility preservation option for people undergoing cancer treatment.
  • Microsurgical testicular sperm extraction (microTESE). The microTESE procedure allows semen to be extracted directly from the testes. Samples are analyzed and frozen for future use, if the sperm is viable.

ESSM Is a New Option

You have to undergo semen analysis to find out your sperm count and to learn more about the quality of your sperm. With traditional semen analysis, many people find that they have low sperm counts. Some people are told that they have no sperm, which is also referred to as azoospermia. 

With the ESSM process, providers are able to find and freeze sperm in people with low sperm counts, including people with azoospermia. The limited fertility options available make the ESSM procedure an attractive new option for transgender women undergoing gender-affirming care. 

How ESSM Works

Sperm collection cup

ESSM is an advanced semen evaluation and processing technique. It allows providers to effectively locate and freeze sperm in the semen of people with low sperm counts. It’s exclusively performed by Maze

The ESSM Process

The ESSM process differs from standard semen analysis. Steps include:

  • Sampling. First, a person provides a semen sample, as they would for a standard semen analysis. 
  • Processing. The team processes the sample, dividing the entire semen sample into five microliter droplets.
  • Scanning. The team spends several hours carefully scanning the droplets using a high-powered microscope. This allows them to identify sperm that may have been missed during standard semen analysis.
  • SpermVD. The sperm are then placed on a device, called SpermVD. This specialized device allows individual sperm to be transferred to a microdroplet prior to freezing.
  • Cryopreservation. The sperm are frozen in a small quantity of fluid for later use by a process called intracytoplasmic sperm injection (ICSI-IVF).
  • Injection. Sperm are thawed for injection into an egg (ICSI-IVF). 

Advantages of ESSM

ESSM may open doors for people who haven’t had success with traditional semen analysis and preservation techniques.

Advantages of ESSM include:

  • Efficient process. ESSM allows providers to find more sperm than standard semen collection can. The process also allows for quicker identification of sperm, which means it can be used as soon as eggs are available, improving rates of fertilization.
  • Strong results. ESSM has had promising results in people with low sperm counts. In fact, recent findings show that ESSM was successful in finding and freezing sperm in 44 percent of men with azoospermia. 
  • Sperm survival. Over 90 percent of sperm survive the freezing and thawing process. 
  • Less invasive. ESSM is less invasive than the microTESE procedure; it only involves ejaculating into a specimen collection cup and doesn’t carry risk for damage to the testes. Some people also find the microTESE procedure to be painful.

Though it was produced as a fertility option for men with low sperm counts, ESSM could benefit transgender women as well. ESSM provides transgender women with improved odds of finding viable sperm to preserve as well as a less-invasive option than microTESE.

Disadvantages of ESSM

ESSM is still considered a new procedure. Additional research is needed to identify potential benefits and disadvantages for its use in transgender women. 

Current disadvantages of ESSM include:

  • High costs. Fertility preservation can be expensive. Clients must pay for the collection, freezing, and storage of their sperm. 
  • Risk of decreased sperm viability. All fertility preservation comes with the risk of reduced sperm viability during the freezing and thawing process.
  • Potential increased risk for miscarriage. Couples using sperm from both traditional cryopreservation and the ESSM process may have a higher risk of miscarriage. 
  • Testosterone production. ESSM requires consistent testosterone production. 



Transgender women face unique fertility challenges. Many transgender women do not use fertility preservation prior to beginning gender-affirming care.

The new ESSM procedure shows promise as a fertility option for transgender women. It’s less invasive than the TESE procedure and is successful in retrieving viable sperm from people with low sperm counts. Sperm retrieval is possible with ESSM unless sperm production has stopped completely.

Current research on fertility in transgender people is limited. Fortunately, fertility options are available, and research continues to grow. Finding a knowledgeable and friendly healthcare provider can help you to get the fertility treatment you need to start your family.

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