The condition of infertility is defined as the inability to conceive a child within 2 years of regular unprotected sexual intercourse. It is estimated that infertility affects about 12–15 % of the total of couples in reproductive age throughout the world, and it can be therefore considered a social issue.

Every year in Italy about 50,000–70,000 among newly formed couples are destined to suffer from reproductive problems in their future relational experiences. All these couples represent the so-called infertile population. Alongside its medical significance – because inability to procreate is considered a “disease” to all intents and purposes by WHO (World Health Organization) – infertility involves other psychological, familiar and relational aspects.

Heterosexual, homosexual or transsexual, fertile or sterile, the couple remains a symbol of the matching of the two gametes: an archetype that is present in everybody [1]. For this reason, once the transsexual person has completed the transitioning process from both the psychological and the physical point of view¹ she/he may also feel the desire to form a couple that might permit a complete fulfilment of her/his life.

In a context of sexual uncertainty like that of transition, the condition of “couple” may be felt as a strong instrument for the individual existential fulfilment, often superior even to family, work and sexual power.

While in the general population infertility or sterility is usually secondary to a pathology or other physiological factors (e.g. age, genetic factors, etc.), in a transsexual couple they are the direct consequence of the medical surgical procedures that transsexual people undertake to complete their transition.

Nowadays, ARTs (assisted reproductive technologies) include a variety of medical treatments that can provide a solution for many different kinds of infertility factors.

Assisted reproduction techniques are divided in:

The different ART techniques that can apply to transsexual couples depend on several factors, including the kind of modification of one’s sexual traits and, consequently, the type of couple that is formed in the end [7, 8]. These techniques are summarised in Table 40.1.

Among the first group of techniques, intrauterine insemination with heterologous sperm (also known as AID – artificial insemination by donor) is suitable for couples formed by a trans man (FtM) and a cissexual woman [9]. Artificial insemination cannot be considered an assisted reproductive technique proper because the whole fertilisation process happens “in vivo”. It is recommended in those cases when the tubal patency of the female partner has been medically ascertained. It entails the introduction of seminal fluid provided by a donor into the uterine cavity, using an atraumatic catheter which allows a painless passage through the cervical canal. This procedure requires that cryopreserved sperm is thawed and conveniently prepared for insemination.

Several studies stress that success rates of intrauterine insemination (either with heterologous or with homologous sperm) increase when this technique is combined to an ovarian hyperstimulation, which allows the maturation of a higher number of ovulatory follicles.