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Cheng PJ, Pastuszak AW, Myers JB, Goodwin IA, Hotaling JM. Fertility concerns of the transgender patient. Transl Androl Urol 2019; 8:209-218. [PMID: 31380227 DOI: 10.21037/tau.2019.05.09] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Transgender individuals who undergo gender-affirming medical or surgical therapies are at risk for infertility. Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear. Gender-affirming surgery (GAS) that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility. It is recommended that clinicians counsel transgender patients on fertility preservation (FP) options prior to initiation of gender-affirming therapy. Transmen can choose to undergo cryopreservation of oocytes or embryos, which requires hormonal stimulation for egg retrieval. Uterus preservation allows transmen to gestate if desired. For transwomen, the option for FP is cryopreservation of sperm either through masturbation or testicular sperm extraction. Experimental and future options may include cryopreservation and in vitro maturation of ovarian or testicular tissue, which could provide prepubertal transgender youth an option for FP since they lack mature gametes. Successful uterus transplantation with subsequent live birth is a new medical breakthrough for cisgender women with uterus factor infertility. Although it has not yet been performed in transgender women, uterus transplantation is a potential solution for those who wish to get pregnant. The transgender population faces many barriers to care, such as provider discrimination, lack of information, legal barriers, scarcity of fertility centers, financial burden, and emotional cost. Further research is necessary to investigate the feasibility of experimental FP options, provide better evidence-based information to clinicians and transgender patients alike, and to improve access to and quality of reproductive services for the transgender population.
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Affiliation(s)
- Philip J Cheng
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Alexander W Pastuszak
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Jeremy B Myers
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Isak A Goodwin
- Division of Plastic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - James M Hotaling
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA.,Department of Obstetrics & Gynecology, University of Utah, Salt Lake City, UT, USA
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Abstract
Hormonal therapy and gender-affirming surgeries in transgender people have known deleterious impacts on future fertility using one's own gametes. This review focuses on fertility preservation, including the effects of medical hormone treatment on fertility, available and experimental options of fertility preservation in transgender adults, including sperm cryopreservation for transwomen and oocyte cryopreservation for transmen, and options for prepubertal transgender adolescents, including testicular and ovarian tissue cryopreservation. Transgender patients continue to face barriers and receive infrequent counseling regarding fertility preservation. Physicians should ideally counsel and discuss fertility preservation options before transgender patients undergo hormone therapy of gender-affirmation surgery.
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Affiliation(s)
- Michael F Neblett
- Department of Gynecology and Obstetrics, Emory University, Emory University School of Medicine, Glenn Building, 4th Floor-412 B, 69 Jesse Hill Jr. Drive Southeast, Atlanta, GA 30303, USA
| | - Heather S Hipp
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, 550 Peachtree Street, Suite 1800, Atlanta, GA 30308, USA.
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53
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Schneider F, Scheffer B, Dabel J, Heckmann L, Schlatt S, Kliesch S, Neuhaus N. Options for Fertility Treatments for Trans Women in Germany. J Clin Med 2019; 8:jcm8050730. [PMID: 31121910 PMCID: PMC6572223 DOI: 10.3390/jcm8050730] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/01/2019] [Accepted: 05/16/2019] [Indexed: 01/02/2023] Open
Abstract
Fertility preservation in trans women is a crucial but thus far neglected component in the gender confirming treatment in Germany. It is difficult for trans women to access reproductive health care because centers offering treatment, psychological guidance, gender confirming surgery, as well as reproductive health services are scarce in Germany. Legal, social, or financial issues as well as individual patient comorbidities prevent trans women from receiving appropriate counselling. This review provides an overview on options of fertility preservation in trans women. We consider recent publications on testicular regression at the time of gender confirming surgery demonstrating presence of sperm or at least spermatogonia in the majority of tissues. This may open options for cryopreservation of sperm or testicular stem cells in trans women even at the final stage of transition. Hence, standardized urological procedures (i.e., sperm cryopreservation after masturbation or sperm extraction from the testicular tissue) and experimental approaches (cryopreservation of testicular tissue with undifferentiated spermatogonia) can be offered best at the initiation but also during the gender confirming process. However, counselling early in the gender confirming process increases the chances of fertility preservation because gender confirming hormone therapy has an impact on spermatogenesis.
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Affiliation(s)
- Florian Schneider
- Institute of Reproductive and Regenerative Medicine, Centre of Reproductive Medicine and Andrology, Albert-Schweitzer Campus 1, Building D11, 48149 Muenster, Germany.
- Department of Clinical and Surgical Andrology, Centre of Reproductive Medicine and Andrology, Albert-Schweitzer Campus 1, Building D11, 48149 Muenster, Germany.
| | - Bettina Scheffer
- Institute of Reproductive and Regenerative Medicine, Centre of Reproductive Medicine and Andrology, Albert-Schweitzer Campus 1, Building D11, 48149 Muenster, Germany.
| | - Jennifer Dabel
- Institute of Reproductive and Regenerative Medicine, Centre of Reproductive Medicine and Andrology, Albert-Schweitzer Campus 1, Building D11, 48149 Muenster, Germany.
| | - Laura Heckmann
- Institute of Reproductive and Regenerative Medicine, Centre of Reproductive Medicine and Andrology, Albert-Schweitzer Campus 1, Building D11, 48149 Muenster, Germany.
| | - Stefan Schlatt
- Institute of Reproductive and Regenerative Medicine, Centre of Reproductive Medicine and Andrology, Albert-Schweitzer Campus 1, Building D11, 48149 Muenster, Germany.
| | - Sabine Kliesch
- Department of Clinical and Surgical Andrology, Centre of Reproductive Medicine and Andrology, Albert-Schweitzer Campus 1, Building D11, 48149 Muenster, Germany.
| | - Nina Neuhaus
- Institute of Reproductive and Regenerative Medicine, Centre of Reproductive Medicine and Andrology, Albert-Schweitzer Campus 1, Building D11, 48149 Muenster, Germany.
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54
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Ellis SA, Dalke L. Midwifery Care for Transfeminine Individuals. J Midwifery Womens Health 2019; 64:298-311. [DOI: 10.1111/jmwh.12957] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 12/17/2018] [Accepted: 12/31/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | - Lily Dalke
- Planned Parenthood of New York City New York City New York
- NYC Health + Hospitals/Woodhull Brooklyn New York
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55
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Tishelman AC, Sutter ME, Chen D, Sampson A, Nahata L, Kolbuck VD, Quinn GP. Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: qualitative responses to an international survey. J Assist Reprod Genet 2019; 36:579-588. [PMID: 30604136 PMCID: PMC6439053 DOI: 10.1007/s10815-018-1395-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/18/2018] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To examine provider perceptions of practice behaviors and barriers related to fertility counseling, fertility preservation, and family building among transgender patients. METHODS Participants were medical and mental health professionals who treat adult and youth transgender patients. Recruitment occurred online and in person, via professional listservs for transgender professionals, conferences, and gender clinics. From August-November 2017, 110 participants representing nine countries responded to four open-ended questions included on a survey related to provider practice behaviors and perceived barriers to fertility counseling, fertility preservation, and family building with transgender patients. Thematic coding analysis was used to identify themes. RESULTS Multiple themes were identified including the following: access and cost issues; urgency for gender-affirming treatment; patient maturity and inability to make future-oriented decisions; and provider-related challenges pertaining to knowledge, role, and general lack of information in the nascent field of transgender reproductive health. CONCLUSION(S) This study yielded insights into practice behaviors, challenges, and perceived barriers to fertility counseling with transgender individuals and can serve as a basis for intervention development to optimize clinical practices with this population.
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Affiliation(s)
- Amy C Tishelman
- Departments of Endocrinology and Psychiatry, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, 02115, USA.
| | - Megan E Sutter
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, 33612, USA
| | - Diane Chen
- Division of Adolescent Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
- Department of Child and Adolescent Psychiatry, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
- Departments of Psychiatry and Behavioral Sciences, and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Amani Sampson
- Departments of OB-GYN and Population Health, New York University School of Medicine, New York, NY, 10016, USA
| | - Leena Nahata
- Division of Endocrinology and Center for Biobehavioral Health, Nationwide Children's Hospital, Columbus, OH, 43205, USA
- The Ohio State University College of Medicine, Columbus, OH, 43205, USA
| | - Victoria D Kolbuck
- Division of Adolescent Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
| | - Gwendolyn P Quinn
- Departments of OB-GYN and Population Health, New York University School of Medicine, New York, NY, 10016, USA
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56
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Abstract
: Transgender women have recently been acknowledged as a unique and important risk group in HIV research and care. Although transgender men also face specific problems related to HIV infection, less is known about the risk behaviours and HIV prevalence of this important population. This article highlights key issues relating to the epidemiology, prevention, treatment and management of complications of HIV infection in transgender adults living with HIV, and explores future areas for HIV-related research, with the ultimate goal of improving healthcare provision and quality of life for transgender persons worldwide.
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Affiliation(s)
- Jordan E Lake
- University of Texas Health Science Center at Houston, Houston, Texas
| | - Jesse L Clark
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
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57
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Semen Parameters Among Transgender Women With a History of Hormonal Treatment. Urology 2019; 124:136-141. [DOI: 10.1016/j.urology.2018.10.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/09/2018] [Accepted: 10/02/2018] [Indexed: 11/17/2022]
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58
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Nahata L, Chen D, Moravek MB, Quinn GP, Sutter ME, Taylor J, Tishelman AC, Gomez-Lobo V. Understudied and Under-Reported: Fertility Issues in Transgender Youth-A Narrative Review. J Pediatr 2019; 205:265-271. [PMID: 30293639 DOI: 10.1016/j.jpeds.2018.09.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/14/2018] [Accepted: 09/05/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Leena Nahata
- Nationwide Children's Hospital/The Ohio State University, Columbus, OH.
| | - Diane Chen
- Ann and Robert H. Lurie Children's Hospital/Northwestern University, Chicago, IL
| | | | | | - Megan E Sutter
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | - Amy C Tishelman
- Boston Children's Hospital/Harvard Medical School, Boston, MA
| | - Veronica Gomez-Lobo
- Washington Hospital Center/Children's National Medical Center/Georgetown University, Washington, DC
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59
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Abstract
Transfeminine individuals are treated with estradiol and anti-androgen agents to transition to a more feminine appearance. The physical changes that occur with estradiol therapy include breast development, body fat redistribution, and decreased muscle mass. Transfeminine treatment regimens require monitoring and dose adjustments to achieve appropriate physiologic targets to enhance feminization and decrease risk of adverse outcomes. Adverse effects associated with estradiol use include thromboembolic disease, macroprolactinoma, breast cancer, coronary artery disease, cerebrovascular disease, cholelithiasis, and hypertriglyceridemia. Benefits of hormonal treatment may include both an improvement in quality of life and a decrease in gender dysphoria.
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Affiliation(s)
- Jessica Abramowitz
- Division of Endocrinology and Metabolism, Department of Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9302, USA.
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle NE-WMRB 1301, Atlanta, GA 30322, USA
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60
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Mattawanon N, Spencer JB, Schirmer DA, Tangpricha V. Fertility preservation options in transgender people: A review. Rev Endocr Metab Disord 2018; 19:231-242. [PMID: 30219984 DOI: 10.1007/s11154-018-9462-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Gender affirming procedures adversely affect the reproductive potential of transgender people. Thus, fertility preservation options should be discussed with all transpeople before medical and surgical transition. In transwomen, semen cryopreservation is typically straightforward and widely available at fertility centers. The optimal number of vials frozen depends on their reproductive goals and treatment options, therefore a consultation with a fertility specialist is optimal. Experimental techniques including spermatogonium stem cells (SSC) and testicular tissue preservation are technologies currently under development in prepubertal individuals but are not yet clinically available. In transmen, embryo and/or oocyte cryopreservation is currently the best option for fertility preservation. Embryo cryopreservation requires fertilization of the transman's oocytes with a donor or partner's sperm prior to cryopreservation, but this limits his future options for fertilizing the eggs with another partner or donor. Oocyte cryopreservation offers transmen the opportunity to preserve their fertility without committing to a male partner or sperm donor at the time of cryopreservation. Both techniques however require at least a two-week treatment course, egg retrieval under sedation and considerable cost. Ovarian tissue cryopreservation is a promising experimental method that may be performed at the same time as gender affirming surgery but is offered in only a limited amount of centers worldwide. In select places, this method may be considered for prepubertal children, adolescents, and adults when ovarian stimulation is not possible. Novel methods such as in-vitro activation of primordial follicles, in vitro maturation of immature oocytes and artificial gametes are under development and may hold promise for the future.
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Affiliation(s)
- Natnita Mattawanon
- Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Jessica B Spencer
- Division of Reproductive Endocrinology, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - David A Schirmer
- Division of Reproductive Endocrinology, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
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