The Next Frontier in Fertility Treatment ANDY INKSTER, a transgender man, had always wanted biological children. So when he embarked on the transition from female to male at age 18 - changing his name, taking testosterone and eventually undergoing surgery to remove his breasts - he left his female reproductive organs intact. In his mid-20s, he decided it was time. He stopped taking testosterone and started trying to get pregnant. Eventually, in 2009, after beginning graduate school at the University of Massachusetts at Amherst, he sought fertility treatment at Baystate Reproductive Medicine. Baystate was one of the few clinics in the country with an anti-discrimination policy for gender identity. And yet, it refused to treat him, arguing that it didn't have enough expertise to treat transgender patients. Mr. Inkster insisted there was no medical reason to deny him; his baby-making parts were the same as any woman's. The more than 700,000 transgender people living in the United States have long faced discrimination by health care providers. Over the past 15 years, activists have fought to compel insurers to cover transgender-related health care - from hormone therapy to gender reassignment surgery - or at least be prevented from excluding transgender clients from buying policies for basic services. Finally, starting this month, thanks to the Affordable Care Act, "transsexualism" can no longer be considered a pre-existing condition. What's been left out of the spotlight: having babies. Many Americans have come to accept gay parents; the transgender community is next in line for recognition. Mr. Inkster eventually found another clinic that helped him conceive via in vitro fertilization and donor sperm, and in October 2010, he gave birth to a daughter, Elise. A month later, he sued Baystate for sexual discrimination. According to court documents, he was denied treatment after failing to comply with a clinic counselor's request that he supply information from his current therapist that he was emotionally ready to handle pregnancy and parenting. Mr. Inkster argued that nontransgender patients weren't asked to do the same. This fall, the Massachusetts Commission Against Discrimination - the state's civil rights agency - found probable cause for Mr. Inkster. The case will next move on to a conciliation conference, and then to a possible settlement. Admittedly, the idea of a "pregnant man" makes many people uncomfortable, and photos of Mr. Inkster caressing his bulging belly are startling. The issue is controversial even within the transgender community. "Some people believe if you're a trans man you shouldn't be wanting to bear kids," Jamison Green, the author of "Becoming a Visible Man," told me. That's not something men do. Others think, If you have a body part that does something, why can't you use it? It's your body. The issue brings up unprecedented questions: Do you use your genetic material to reproduce, and at what time during your transition? Before or after hormone therapy? Before undergoing reassignment surgery that will make you sterile? Should a transgender man like Mr. Inkster keep his breasts so he can nurse later? Is it generally psychologically healthier for someone like him to freeze his eggs and have them inseminated and the embryos transferred to a female partner or surrogate, rather than leave his female reproductive parts intact? How might years of estrogen or testosterone therapy affect eggs and sperm? These questions matter. One study published last year in the journal Human Reproduction of 90 transgender men in Belgium found that 54 percent wished to have children, and 38 percent would have considered freezing their eggs if the procedure had been available. Other research, published in 2002, by Belgian fertility doctors with Western European transgender women found that 40 percent wanted to have children, and 77 percent felt they should have the option to preserve their sperm before hormone treatment. As fertility technology improves and becomes more widely available, transgender people are realizing that they will have more options in the future. Jennifer Hastings, a family care physician based in Santa Cruz, Calif., who specializes in transgender health care, says it's tricky to balance gender identity with family desires. "We have preteens who come in and say, "I don't want to be a mom. I want to be a dad!" " she says. On the other hand, there are youth who know they want to have biological kids from the outset and freeze sperm or eggs after going through puberty. Since some doctors are concerned that letting transgender teenagers go through puberty in the gender they don't identify with may be deeply traumatic, they might administer puberty-blocking medications that delay adolescence until the teenagers can begin hormone therapy in their desired gender. But this means the patients may give up the option of having biological children later. "It can be a painful choice for their parents to make," says Dr. Hastings. All these paths toward creating transgender families deserve careful study. Yet these issues aren't likely to get the attention they deserve until transgender people succeed in getting basic health care first. Stories of transgender people in health care settings being gawked at, mocked or interrogated about their status abound. A disturbing 2011 study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force of 6,450 transgender adults found that 19 percent reported having been refused treatment by a health care provider because of their gender identity, and 28 percent said they had postponed medical care because of discrimination. For those who had visited a doctor's office or hospital, 24 percent said they had been denied equal treatment, 25 percent reported having been harassed or disrespected, and 2 percent had been physically assaulted. It's understandable that doctors might be nervous about not having enough training to treat people who are under long-term hormone therapy. Medical schools need to make students more aware of transgender health needs, which in most cases aren't that different from everyone else's. "If someone has a sore throat, they have a sore throat," said Dr. Hastings. It's not because of their hormones. The bigger challenge may be to get medical providers to overcome their bias. Discomfort over difference isn't an excuse to refuse compassionate care to a transgender person in an emergency room or a fertility clinic, or for insurance companies to refuse to cover that care. Gender identity has nothing to do with the desire to have children - or with who will make a good parent.