Fertility preservation for trans men: frozen-thawed in vitro matured oocytes collected at the time of ovarian tissue processing exhibit normal meiotic spindles

Fertility in transgender and gender diverse people: systematic review of the effects of gender-affirming hormones on reproductive organs and fertility

BACKGROUND

Transgender and gender diverse (TGD) people seek gender-affirming care at any age to manage gender identities or expressions that differ from their birth gender. Gender-affirming hormone treatment (GAHT) and gender-affirming surgery may alter reproductive function and/or anatomy, limiting future reproductive options to varying degrees, if individuals desire to either give birth or become a biological parent.

OBJECTIVE AND RATIONALE

TGD people increasingly pursue help for their reproductive questions, including fertility, fertility preservation, active desire for children, and future options. Their specific needs certainly require more insight into the effects of GAHT on gonads, gametes, and fertility. This systematic review aims to provide an overview of the current knowledge on the impact of GAHT on gonads, gametes, fertility, fertility preservation techniques, and outcomes.

SEARCH METHODS

This review was registered in the PROSPERO registry under number CRD42024516133. A literature search (in PubMed, Embase, and Web of Science) was performed with a medical information specialist until 15 November 2024.

OUTCOMES

In all TGD people using GAHT, histological changes have been reported.Using testosterone GAHT, ovarian cortical and stromal changes were reported by various studies. In most studies, persistent activity in folliculogenesis can be concluded based on the descriptions of the follicle count, distribution, and oocyte retrieval yield. However, there may be a negative effect on the fertilization rate in the presence of testosterone. Reports of successful ovarian stimulation, fertilization, pregnancies, and live births have been published, describing cases with and without testosterone discontinuation.After using oestrogen GAHT, testes are reported to be more atrophic, including smaller seminiferous tubules with heavy hyalinization and fibrosis. Spermatogenic levels varied widely from complete spermatogenesis to meiotic arrest with spermatids, to spermatogonial arrest, Sertoli cells only, or even tubular shadows. Oestrogen and anti-androgen treatment causes higher proportions of sperm abnormalities (i.e. low total sperm count, low sperm concentration, poor sperm motility) or azoospermia. However, after cessation, this may be restored.

WIDER IMPLICATIONS

Although knowledge of the effect of GAHT is growing, blind spots remain to be uncovered. Therefore, additional research in this specific population is needed, preferably comparing outcomes before and after the start of GAHT. This may help to reveal the pure impact of GAHT on reproductive functioning. Research suggestions also include investigations into the reversibility of the GAHT effect, especially for those who start transition at a young age. Looking carefully at the presented data on GAHT effects on gonads and gametes, the correct advice is to assess and reassess reproductive wishes and preferences repeatedly, and also to explore individual fertility preservation needs during gender-affirming treatment, given the expanding knowledge and therapy opportunities. Finally, concerns regarding long-term health outcomes and quality of life of children born by the use of gametes preserved after exposure to GAHT require prospective follow-up studies.

The intersection of the laboratory and transgender care

Transgender and gender diverse (TGD) individuals seeking gender affirming treatment are an increasing demographic in today's society; such treatments include hormonal and surgical interventions aimed at alleviating gender dysphoria and increasing quality of life. A number of diagnostic pathology tests are provided to medical professionals with sex specific reference intervals (RIs) for interpretation, due to sex specific physiological differences, organ size and hormone levels for example. These tests may be reported with RIs that are not appropriate, and interpretation for the medical professional can be challenging. From the laboratory perspective, there are limitations in Laboratory Information Management Systems (LIMS) and the ability of these databases to record both sex and gender identifiers, as well as the reporting of appropriate RIs. The use of RIs derived from the transgender population is complex, studies generally have a low sample size and include adults with long established hormonal treatments. The age of an individual undergoing gender affirming therapy has decreased, and the use of Gonadotrophin Releasing Hormone analogues adds complexity. In this review, we will discuss the current challenges and perspectives regarding the reporting of reference intervals in the TGD population, the derivation of personalized or transgender specific RIs and interpretation of specific diagnostic tests.

Reproductive functions and fertility preservation in transgender men: A French case series

BACKGROUND

Transgender men face reproductive challenges due to the potential impact on fertility of gender-affirming hormone therapy (GAHT) and surgical interventions. Testosterone therapy during "female to male" transition leads to anovulation and amenorrhea. Although these effects are typically reversible upon stopping treatment, the long-term effects of androgens on future fertility and health of potential children remain poorly known. Despite being long overlooked, the desire for parenthood is a significant reality among transgender men. Advances in medical techniques and legislative changes now make fertility preservation (FP), primarily through oocyte cryopreservation, possible for transgender men. Yet, published data on FP outcomes for this population are still limited.

DESIGN

We conducted a retrospective study to compare ovarian stimulation outcomes between transgender men and presumed fertile women from an oocyte donation program.

RESULTS

Between June 2018 and February 2022, 118 transgender men were referred to the FP consultation, of whom 13 ultimately underwent FP through oocyte vitrification following ovarian stimulation. These 13 individuals were compared to a control group of 13 matched female oocyte donors. We did not observe any significant difference in the clinical and biological outcomes of ovarian stimulation, including duration of stimulation, total FSH dose administered, number of oocytes retrieved, and number of mature oocytes obtained.

CONCLUSION

Our experience suggests that FP through oocyte vitrification after ovarian stimulation is feasible and effective for transgender men, with outcomes comparable to those of cisgender women of the same age. Larger studies are necessary to validate these findings and assess the long-term success rates.

In vitro growth of secondary follicles from cryopreserved-thawed ovarian cortex

STUDY QUESTION

Can secondary follicles be obtained from cultured cryopreserved-thawed human ovarian cortical tissue?

SUMMARY ANSWER

We obtained high-quality secondary follicles from cultured cryopreserved-thawed human ovarian cortical tissue from cis female donors (cOVA), but not from trans masculine donors (tOVA) in the same culture conditions.

WHAT IS KNOWN ALREADY

The in vitro growth of oocytes present in unilaminar follicles into metaphase II stage (MII) oocytes has been previously achieved starting from freshly obtained ovarian cortical tissue from adult cis female donors. This involved a multi-step culture protocol and the first step included the transition from unilaminar follicles to multilayered secondary follicles. Given that the ovarian cortex (from both cis female and trans masculine donors) used for fertility preservation is cryopreserved, it is crucial to investigate the potential of unilaminar follicles from cryopreserved-thawed ovarian cortex to grow in culture.

STUDY DESIGN, SIZE, DURATION

Cryopreserved-thawed ovarian cortical tissue from adult trans masculine donors (n = 3) and adult cis female donors (n = 3) was used for in vitro culture following the first culture step described in two published culture protocols (7-8 days and 21 days) and compared to freshly isolated ovarian cortex from trans masculine donors (n = 3) and to ovarian cortex prior to culture.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Ovarian cortical tissue was obtained from adult trans masculine donors undergoing gender-affirming surgery while using testosterone, and from adult cis female donors undergoing oophorectomy for fertility preservation purposes before chemotherapy. The ovarian cortex was fixed either prior (day 0) or after the culture period. Follicular survival, growth, and morphology were assessed through histology and immunofluorescence.

MAIN RESULTS AND THE ROLE OF CHANCE

We quantified the different stages of follicular development (primordial, primary, secondary, and atretic) after culture and observed an increase in the percentage of secondary follicles as well as an increase in COLIV deposition in the stromal compartment regardless of the culture media used. The quality of the secondary follicles obtained from cOVA was comparable to those prior to culture. However, in the same culture conditions, the secondary follicles from tOVA (fresh and cryo) showed low-quality secondary follicles, containing oocytes with small diameter, granulosa cells that expressed abnormal levels of KRT19 and steroidogenic-marker STAR and lacked ACTA2+ theca cells, when compared to tOVA secondary follicles prior to culture.

LIMITATIONS, REASONS FOR CAUTION

The number of different donors used was limited.

WIDER IMPLICATIONS OF THE FINDINGS

Our study revealed that cryopreserved-thawed cOVA can be used to generate high-quality secondary follicles after culture and those can now be further tested to evaluate their potential to generate functional MII oocytes that could be used in the clinic. However, using the same culture protocol on tOVA (fresh and cryo) did not yield high-quality secondary follicles, suggesting that either the testosterone treatment affects follicular quality or adapted culture protocols are necessary to obtain high-quality secondary follicles from tOVA. Importantly, caution must be taken when using tOVA to optimize folliculogenesis in vitro.

STUDY FUNDING/COMPETING INTEREST(S)

This research was funded by the European Research Council Consolidator Grant OVOGROWTH (ERC-CoG-2016-725722 to J.S.D.V. and S.M.C.D.S.L.), the Novo Nordisk Foundation (reNEW NNF21CC0073729 to H.C., F.W., J.S.D.V., S.M.C.D.S.L.), and China Scholarship Council (CSC 202008320362 and CSC 202008450034 to H.C. and F.W.), respectively. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

NASPAG Clinical Opinion: The Care of Transgender and Gender Nonbinary Adolescents and Young Adults

Transgender and gender nonbinary (TGNB) adolescents and young adults (AYA) may present to clinicians with reproductive health expertise for the spectrum of gynecologic, sexual, and reproductive care. As such, clinicians should be knowledgeable in the many facets of gender-affirming care. This clinical opinion reviews language associated with gender diversity and gender-affirming care; current clinical, social, and political barriers faced by TGNB AYA; and the creation of welcoming and inclusive clinical spaces for TGNB AYA. It discusses social, medical, and surgical affirmation processes, and focuses on gynecologic care topics which may arise in the care of TGNB AYA, including those who undergo medical or surgical therapies. This includes menstrual suppression, breakthrough bleeding on testosterone, sexual health, fertility, and the pelvic care of individuals following gender affirming vulvovaginoplasty.

Medical and Surgical Reproductive Care of Transgender and Gender Diverse Patients

Transgender and gender nonbinary (TGNB) patients may seek out gynecologic care for a variety of reasons. It is important for gynecologic providers to possess a comprehensive understanding and comfort level in caring for TGNB adolescents and young adults. This piece discusses the gynecologic care of TGNB adolescents and young adults. It reviews disparities faced by TGNB adolescents, social, medical, and surgical affirmation approaches to gender affirming care, and gynecologic health considerations including fertility, menstrual suppression, breakthrough bleeding and vulvovaginal atrophy on testosterone, hysterectomy and oophorectomy approaches, as well as pelvic health care following gender-affirming penile inversion vulvovaginoplasty.

Reproductive Health in Trans and Gender Diverse Patients: Effects of transmasculine gender-affirming hormone therapy on future reproductive capacity: clinical data, animal models, and gaps in knowledge

In brief

Animal studies are needed to inform clinical guidance on the effects of testosterone gender-affirming hormone therapy (T-GAHT) on fertility. This review summarizes current animal models of T-GAHT and identifies gaps in knowledge for future study.

Abstract

Testosterone gender affirming hormone therapy (T-GAHT) is frequently used by transgender and gender-diverse individuals assigned female at birth to establish masculinizing characteristics. Although many seek parenthood, particularly as a gestational parent or through surrogacy, the current standard guidance of fertility counseling for individuals on testosterone (T) lacks clarity. At this time, individuals are typically recommended to undergo fertility preservation or stop treatment, associating T-therapy with a loss of fertility; however, there is an absence of consistent information regarding the true fertility potential for transgender and gender-diverse adults and adolescents. This review evaluates recent studies that utilize animal models of T-GAHT to relate to findings from clinical studies, with a more specific focus on fertility. Relevant literature based on murine models in post- and pre-pubertal populations has suggested reversibility of the impacts of T-GAHT, alone or following gonadotropin-releasing hormone agonist (GnRHa), on reproduction. These studies reported changes in clitoral area and ovarian morphology, including corpora lutea, follicle counts, and ovarian weights from T-treated mice. Future studies should aim to determine the impact of the duration of T-treatment and cessation on fertility outcomes, as well as establish animal models that are clinically representative of these outcomes with respect to gender diverse populations.

New Insights on In Vitro Maturation of Oocytes for Fertility Preservation

In the last decade, the evolution of oncofertility has sparked a resurgence of interest in in vitro maturation (IVM) due to its suitability in certain oncological scenarios where controlled ovarian hyperstimulation may not be feasible. The retrieval of immature cumulus-oocyte complexes from small antral follicles, regardless of the menstrual cycle phase, presents a swift opportunity to vitrify mature oocytes or embryos post-IVM in urgent situations or when stimulation is not advisable. Harvesting immature cumulus-oocyte complexes and immature oocytes can be achieved transvaginally or directly in the laboratory from extracorporeal ovarian tissue. Although IVM has transitioned from an experimental status due to safety validations, it relies on the intricate process of oocyte maturation. Despite successful live births resulting from IVM in fertility preservation contexts, the comparatively lower developmental competence of in vitro matured oocytes highlights the necessity to enhance IVM culture systems. Recent advancements in IVM systems hold promise in bolstering oocyte competence post-IVM, thereby narrowing the gap between IVM and outcomes from ovarian stimulation. Additionally, for optimizing the chances of conception in cancer survivors, the combination of IVM and ovarian tissue cryopreservation stands as the favored choice when ovarian stimulation is unfeasible.

Encapsulation of Bovine Primordial Follicles in Rigid Alginate Does Not Affect Growth Dynamics

The only fertility preservation and subsequent restoration option for many patients facing gonadotoxic treatments is ovarian tissue cryopreservation and transplantation. While this process is successful for some, there is significant room for improvement to extend the life of the transplant and to make it safe for patients that may have metastatic disease within their ovarian tissue. We need a deeper understanding of how the physical properties of the ovarian microenvironment may affect folliculogenesis to engineer an environment that supports isolated follicles and maintains primordial follicle quiescence. Bovine ovaries were used here as a monovulatory model of folliculogenesis to examine the effects of primordial follicle activation and growth under different physical conditions. We found that there were no differences in activation, growth or survival when primordial follicles were cultured in isolation or in situ (remaining in the tissue) under two significantly differently rigid alginate gels. To determine if the extra rigid environment did not affect activation in isolated follicles due to an immediate activation event, we used 5-ethynyl-2'-deoxyuridine (EdU) to track follicle activation during the isolation process. We identified EdU incorporation in granulosa cells after primordial follicles were isolated from the surrounding extracellular matrix (ECM). These findings support that isolation of primordial follicles from the ECM is an activating event and that the differentially rigid environments assessed here had no effect on follicle growth. Further work is needed to suppress activation in primordial follicles to maintain the ovarian reserve and extend the life of an ovarian tissue transplant.

First Childbirth after Fertility Preservation and Gender Reassigning Surgery from Indian Transgender Community

Fertility preservation (FP) is critical for those members of the transgender community who desire biological offspring in the future. As gender-affirming hormone therapy and gender-affirming surgeries (GASs) negatively affect future fertility potential, awareness amongst care providers and the transgender population regarding FP and family-building options is the need of the hour. As the first case of childbirth after transgender FP and GAS in India, this will be a beacon of hope for transgender family-building options in India.

Barriers to fertility preservation access in transgender and gender diverse adolescents: a narrative review

Fertility preservation (FP) involves the cryopreservation of gametes, embryos, and/or gonadal tissue oocytes, for future use in family building. FP as part of a comprehensive approach to care of transgender and gender diverse (TGD) individuals is an understudied topic. Current evidence indicates that gender affirming therapies may increase the risk for infertility. As a result, TGD individuals, including adolescents, should receive counseling regarding FP prior to beginning gender affirming treatment. Many barriers exist to TGD adolescents receiving FP counseling and undergoing FP if desired. The objective of this narrative review is to summarize the literature regarding the desire for FP in TGD adolescents, the barriers to TGD adolescents in accessing of FP, and to discuss potential interventions for alleviation of such barriers. A literature search using the following Medical Subject Headings search terms: 'transgender persons' and 'fertility preservation' and 'adolescents' was conducted via searching PubMed. Additional articles were located via reference review. Included articles consist of qualitative and quantitative research and society guidelines. Articles from inception to 1st July 2023 were included. The results of the literature search have been summarized into the format of a narrative review. Key barriers to FP for TGD adolescents include inconsistencies in form and timing of counseling, potential worsening of gender dysphoria with FP treatment, high cost of treatment, limited research on FP outcomes, and legal barriers. Intersectionality between gender identity and other forms of minority status can compound these barriers to FP and healthcare in general. Barriers to TGD adolescents accessing FP are significant. Increased research is needed upon methods to mitigate these barriers. Solutions include increasing uniformity and timing of FP counseling by varying health care providers, advocacy efforts to mitigate legal and financial barriers, increased research efforts in FP outcomes, and increased cultural competency in clinics offering FP care to TGD adolescents.

Clinical management of transgender and non-binary patients in the fertility preservation service: Current evidence

Background: Transgender and non-binary individuals face unique challenges when it comes to fertility preservation (FP). Objective: Despite the growing prevalence of gender dysphoria (GD) and gender transitioning, there is a lack of clear guidelines and consensus on the management of these patients in the FP setting. Clinicians and institutions providing FP services should ensure that they are aware of the needs and circumstances of this underrepresented group of patients and offer them accurate and evidence-based information when counseling and tailoring their FP treatment. Materials and methods: For this scoping review, three major search engines were used. Including Embase, Epistemonikos, Google Scholar, MEDLINE and PubMed. Sources of grey literature were also explored (ResearchGate and Web of Science). The combination of only two keywords [transgender] AND [fertility preservation] was used up to May 2023. Results: The available evidence on clinical management and FP outcomes in transgender patients is limited and mainly originates from case reports or small case series. The main limitation of current FP services for transgender and non-binary individuals is the lack of scientific evidence regarding their care. Discussion: Overall, FP in transgender patients requires individualized and realistic plans, and psychological counseling should be offered. This review aims to provide the latest evidence coming from original studies to facilitate proper counseling and fertility management for these individuals. Conclusions: Inclusive health systems that provide comprehensive reproductive health care to transgender individuals can help them make informed decisions about FP and improve their quality of life. Future research is needed to establish more robust evidence-based guidelines for the management of transgender and non-binary individuals in the FP setting.

[Transition, fertility and options for preservation of fertility]

Oftentimes ignored or infrequently expressed, some transgender persons harbor a desire for parenthood. Given the evolution of medical techniques and the enacting of legislative reforms, it is henceforth possible to propose fertility preservation strategies in the overall context of gender transidentity. During the "female to male" (FtM) transition pathway, androgen therapy has an impact on gonadic function, generally inducing blockage of the ovarian function, with amenorrhea. Even though these events may be reversed on cessation of treatment, the possible long-term effects on future fertility and on the health of children yet to be born are little known. Moreover, transition surgeries definitively compromise the possibility of pregnancy insofar as they involve bilateral adnexectomy and/or hysterectomy. Options for fertility preservation in the framework of FtM transition are premised on cryopreservation of oocytes and/or ovarian tissue. In a comparable manner, even though relevant documentation is lacking, hormonal treatments for persons transitioning from male to female (MtF) can have an impact on future fertility. In the event of surgery involving bilateral orchidectomy in which spermatozoid cryopreservation has not been carried out, fertility is definitively impossible. In both cases and under present-day legislation, numerous legal and regulatory barriers render highly problematic the reutilization of cryopreserved gametes. Given these different constraints, it is indispensable to closely supervise these types of treatment by proposing psychological support.

Reproductive capacity after gender-affirming testosterone therapy

Transgender and nonbinary people with female birth sex may utilize testosterone therapy for masculinization. Individuals interested in reproduction using their own gametes should be offered fertility preservation prior to starting testosterone. However, logistical and practical barriers prevent many from accessing fertility preservation options prior to starting testosterone. Some of these transmasculine and nonbinary individuals may later become interested in carrying a pregnancy or using their oocytes for reproduction after being on testosterone. Many questions remain about the reproductive impact of long-term masculinizing testosterone therapy. Emerging literature has documented pregnancies and successful assisted reproduction for some people after taking testosterone, but it is not known whether individuals can expect these successful outcomes. Testosterone appears to impact the reproductive tract, including the ovaries, uterus, and fallopian tubes, but the reversibility and functional impact of these changes also remain unclear. A greater understanding of the impact of masculinizing testosterone on reproductive capacity remains a priority area for future research.

Preservation of Fertility in Transgender Men on Long-Term Testosterone Therapy: A Systematic Review of Oocyte Retrieval Outcomes During and After Exogenous Androgen Exposure

Testosterone therapy prompts the development of male secondary sexual characteristics coupled with numerous physiological changes; however, the effect of prolonged androgen exposure on transgender men's fertility remains to be fully elucidated. Multiple clinical consensuses advise assisted reproduction before hormone treatment and state that fertility preservation following androgen therapy entails the suspension of testosterone administration. Although the desire for reproduction among transgender men is prevalent, the discontinuation of gender-affirming hormone therapy poses a major challenge due to the anxiety, unease, and gender dysphoria that follow androgen withdrawal. The present investigation aimed to explore the feasibility and outcomes of oocyte retrieval in adult transgender men undergoing testosterone administration before or during fertility preservation. Seven case reports, four cohort studies, and two cross-sectional studies were identified following a systematic literature search on the PubMed/Ovid MEDLINE, Scopus, and ScienceDirect databases. The findings gathered in this review disclose the viability of oocyte retrieval after prolonged androgen exposure and suggest the absence of a direct relationship between the duration of testosterone suspension and fertility preservation outcomes. Although the reports are limited, recent evidence shows that continuous testosterone administration and the use of aromatase inhibitors during ovarian stimulation could potentially reduce the distressing effects of hormonal ovulation induction. New approaches to fertility preservation in transgender men must be further explored to ensure interventions aligned both with the reproductive desire and avoidance of gender dysphoria exacerbation that follow hormone therapy suspension.

Impaired in vitro fertilization outcomes following testosterone treatment improve with washout in a mouse model of gender-affirming hormone treatment

BACKGROUND

The impact of gender-affirming testosterone on fertility is poorly understood, with ovarian histopathologic studies showing variable results, some with a detrimental effect on reproductive capacity and uncertain reversibility. Assisted reproductive outcome data are restricted to small case series that lack the ability to inform clinical practice guidelines and limit fertility preservation counseling for transgender and nonbinary individuals.

OBJECTIVE

This study aimed to determine the impact of current testosterone and testosterone washout on in vitro fertilization outcomes in a mouse model for gender-affirming hormone treatment. We hypothesized that current or previous testosterone treatment would not affect in vitro fertilization outcomes.

STUDY DESIGN

C57BL/6N female mice (n=120) were assigned to 4 treatment groups: (1) current control, (2) current testosterone, (3) control washout, and (4) testosterone washout. Testosterone implants remained in situ for 6 or 12 weeks, representing the short- and long-term treatment arms, respectively. Current treatment groups underwent ovarian stimulation with implants in place, and washout treatment groups were explanted and had ovarian stimulation after 2 weeks. Oocytes were collected, fertilized, and cultured in vitro, with one arm continuing to the blastocyst stage and the other having transfer of cleavage-stage embryos. Statistical analysis was performed using GraphPad Prism, version 9.0 and R statistical software, version 4.1.2, with statistical significance defined by P<.05.

RESULTS

Current long-term testosterone treatment impaired in vitro fertilization outcomes, with fewer mature oocytes retrieved (13.7±5.1 [standard deviation] vs 28.6±7.8 [standard deviation]; P<.0001) leading to fewer cleavage-stage embryos (12.1±5.1 vs 26.5±8.2; P<.0001) and blastocysts (10.0±3.2 vs 25.0±6.5; P<.0001). There was recovery of in vitro fertilization outcomes following washout in the short-term treatment cohort, with incomplete reversibility in the long-term cohort. Testosterone did not negatively affect maturity, fertilization, or blastulation rates.

CONCLUSION

In a mouse model of gender-affirming hormone treatment, testosterone negatively affected oocyte yield without affecting oocyte quality. Our findings suggest that testosterone reversibility is duration-dependent. These results demonstrate the feasibility of in vitro fertilization without testosterone discontinuation while supporting a washout period for optimization of mature oocyte yield.

"Lights and Shades" of Fertility Preservation in Transgender Men Patients: A Clinical and Pathological Review

Fertility preservation (FP) is becoming a critical issue in transgender men who desire biological offspring in the future. The prevalence of transgender individuals in the United States is increasing, and as a result, the demand for gender-affirming surgeries (GAS) and associated FP techniques is rising. Despite the growing demand, there is currently no personalized approach to FP for transgender men, and the available techniques have limitations that require further investigation. In the present review we carefully examine the existing literature on this topic to highlight the shortcomings of current methods and areas where additional research is needed to advance the field. Hormonal therapy (HT), which is an integral part of gender transition in transgender men, can have a significant impact on fertility and may increase the risk of various diseases. Moreover, GAS usually leads to permanent sterility in these patients. Therefore, it is essential to provide patients with accurate information about the benefits and potential risks of different FP techniques, taking into account the patient's reproductive goals. This review underscores the complex and multifaceted nature of FP in transgender men and emphasizes the need for further research to develop more effective and personalized approaches to FP for this population.

Fertility preservation in pediatric healthcare: a review

Survival rates for children and adolescents diagnosed with malignancy have been steadily increasing due to advances in oncology treatments. These treatments can have a toxic effect on the gonads. Currently, oocyte and sperm cryopreservation are recognized as well-established and successful strategies for fertility preservation for pubertal patients, while the use of gonadotropin-releasing hormone agonists for ovarian protection is controversial. For prepubertal girls, ovarian tissue cryopreservation is the sole option. However, the endocrinological and reproductive outcomes after ovarian tissue transplantation are highly heterogeneous. On the other hand, immature testicular tissue cryopreservation remains the only alternative for prepubertal boys, yet it is still experimental. Although there are several published guidelines for navigating fertility preservation for pediatric and adolescent patients as well as transgender populations, it is still restricted in clinical practice. This review aims to discuss the indications and clinical outcomes of fertility preservation. We also discuss the probably effective and efficient workflow to facilitate fertility preservation.

Retrospective review of changes in testosterone dosing and physiologic parameters in transgender and gender-diverse individuals following hysterectomy with and without oophorectomy

BACKGROUND

As more transgender and gender-diverse patients undergo hysterectomy, gaps in knowledge remain about how testosterone dosing or other physiologic parameters change following surgery and how these are influenced by concomitant oophorectomy.

AIM

The aims of this study were to determine the incidence of testosterone dosing change after gender-affirming hysterectomy and to compare this incidence between patients who underwent oophorectomy and ovarian preservation.

METHODS

This multicenter retrospective cohort study consisted of transmasculine patients who underwent hysterectomy for gender affirmation.

OUTCOMES

Outcome measures included testosterone dosing changes at least 3 months following hysterectomy, as identified by clinical documentation, as well as clinical and laboratory parameters assessed for a change after hysterectomy: free and total testosterone, estradiol, hemoglobin, hematocrit, total cholesterol, weight, and blood pressure.

RESULTS

Of the 50 patients, 32 (64%) underwent bilateral oophorectomy, 10 (20%) unilateral oophorectomy, and 8 (16%) maintained both ovaries. Eight percent (n = 4) changed testosterone dosing following hysterectomy. Those who underwent bilateral oophorectomy were no more likely to change their testosterone dose than those who did not (P = .09). Those who also used menstrual suppression were 1.31 times more likely to change doses of testosterone after hysterectomy (95% CI, 1.09-1.82; P = .003). For those who had pre- and posthysterectomy laboratory and clinical values, the majority saw no clinically significant change. However, among patients who underwent bilateral oophorectomy, the calculated free testosterone increased by 90.1 ± 288.4 ng/dL (mean ± SD), and estradiol dropped by 20.2 ± 29.0 pg/mL.

CLINICAL IMPLICATIONS

In a field where access to care can be a significant barrier, there is unlikely to be a need for routine reassessment of testosterone dose or laboratory parameters following hysterectomy, whether or not a bilateral oophorectomy occurs.

STRENGTHS AND LIMITATIONS

Limitations of the study include its retrospective nature and the lack of consistent clinical laboratory testing, which resulted in limited data about any given hormonal change. The heterogeneity of our population limited the number of patients undergoing or not undergoing oophorectomy; however, it allowed our study to more truly reflect a clinical environment.

CONCLUSION

In a multisite cohort of individuals who underwent hysterectomy for gender affirmation, few patients changed testosterone dosing after surgery. In addition, dosing change was not associated with the presence or absence of bilateral oophorectomy, and most measured laboratory values remained consistent following hysterectomy.

The ovaries of transgender men indicate effects of high dose testosterone on the primordial and early growing follicle pool

Androgens are essential in normal ovarian function and follicle health but hyperandrogenism, as seen in polycystic ovary syndrome, is associated with disordered follicle development. There are few data on the effect of long-term exposure to high levels of testosterone as found in transgender men receiving gender-affirming endocrine therapy. In this study, we investigate the effect of testosterone on the development, morphological health and DNA damage and repair capacity of human ovarian follicles in vivo and their survival in vitro. Whole ovaries were obtained from transgender men (mean age: 27.6 ± 1.7 years; range 20-34 years, n = 8) at oophorectomy taking pre-operative testosterone therapy. This was compared to cortical biopsies from age-matched healthy women obtained at caesarean section (mean age: 31.8±1.5 years; range= 25-35 years, n=8). Cortical tissues were dissected into fragments and either immediately fixed for histological analysis or cultured for 6 days and subsequently fixed. Follicle classification and morphological health were evaluated from histological sections stained with H&E and expression of γH2AX as a marker of DNA damage by IHC. In uncultured tissue, testosterone exposure was associated with reduced follicle growth activation, poor follicle health and increased DNA damage. After 6 days of culture, there was enhanced follicle activation compared to control with further deterioration in morphological health and increased DNA damage. These data indicate that high circulating concentrations of testosterone have effects on the primordial and small-growing follicles of the ovary. These results may have implications for transgender men receiving gender-affirming therapy prior to considering pregnancy or fertility preservation measures.

Desire for children and fertility preservation in transgender and gender-diverse people: A systematic review

The decision to pursue one's desire for children is a basic human right. For transgender and gender-diverse (TGD) people, gender-affirming care may alter the possibilities to fulfill one's desire for children due to the impact of this treatment on their reproductive organs. We systematically included 76 studies of varying quality describing the desire for children and parenthood; fertility counseling and utilization; and fertility preservation options and outcomes in TGD people. The majority of TGD people expressed a desire for children. Fertility preservation utilization rates were low as there are many barriers to pursue fertility preservation. The most utilized fertility preservation strategies include oocyte vitrification and sperm banking through masturbation. Oocyte vitrification showed successful outcomes, even after testosterone cessation. Sperm analyses when banking sperm showed a lower quality compared to cis male samples even prior to gender-affirming hormone treatment and an uncertain recovery of spermatogenesis after discontinuing treatment.

[Fertility preservation for transmen]

The evolution of medical techniques as well as legislative changes currently allow to propose fertility preservation strategies in the context of transidentity. During "female to male" transition, androgen therapy has an impact on gonadal function since it usually induces a blockage of ovulation with amenorrhea. Although this effect is reversible when treatment is stopped, the possible long-term effects of testosterone treatment on future fertility or health of future children are poorly known. In addition, transitional surgeries definitely compromise fecundity when they include bilateral ovariectomy and/or hysterectomy. Yet, although long ignored or poorly expressed, the desire for parenthood is a reality in transgender men. Fertility preservation options in FtM transition rely on oocyte or ovarian tissue cryopreservation. The purpose of this review is to provide an overview of the literature regarding fertility preservation in transgender men. Although series remain limited, the increase in the number of recently published articles reflects the interest in improving the management of fertility issues in transgender men.

Préservation de la fertilité chez les personnes transgenres

La majorité des personnes transgenres envisage de fonder une famille, mais leur fertilité peut être altérée par l’affirmation du genre. L’hormonothérapie peut affecter durablement la production de gamètes, notamment chez les femmes trans. La chirurgie de réassignation sexuelle entraîne une stérilité définitive. En France, des réseaux de professionnels de santé se sont organisés. Ils recommandent l’accès à la préservation de la fertilité dans le cadre de la transidentité. Cependant, le recueil de gamètes reste souvent difficile en raison de l’incongruence hormonale pour les femmes trans, ou du caractère invasif de la procédure pour les hommes trans. De futures études permettront de statuer sur l’utilisation des gamètes autoconservés.

Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review

INTRODUCTION

The transmasculine and gender diverse (TMGD) spectrum includes transgender men and non-binary individuals whose sex was assigned female at birth. Many TMGD patients pursue treatment with exogenous testosterone to acquire masculine characteristics. Some may choose to undergo gynecological gender-affirming surgery for total hysterectomy with bilateral salpingectomy and/or bilateral oophorectomy (TH/BSO). The decision to retain or remove the ovaries in the setting of chronic testosterone therapy has implications on reproductive health, oncologic risk, endocrine management, cardiovascular health, bone density and neurocognitive status. However, there is limited evidence on the long-term outcomes from this intervention.

OBJECTIVE

Here we review health-related outcomes of oophorectomy in TMGD population treated with chronic testosterone therapy in order to guide clinicians and patients in the decision to retain or remove their ovaries.

METHOD

We conducted a systematic literature review following PRISMA guidelines. MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library databases were searched for peer-reviewed studies published prior to October 26, 2021 that: (i) included transgender men/TMGD individuals in the study populations; (ii) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (iii) specifically discussed ovaries, hysterectomy, oophorectomy, ovariectomy, or gonadectomy.

RESULTS

We identified 469 studies, of which 39 met our inclusion criteria for this review. Three studies discussed fertility outcomes, 11 assessed histopathological changes to the ovaries, 6 discussed ovarian oncological outcomes, 8 addressed endocrine considerations, 3 discussed cardiovascular health outcomes, and 8 discussed bone density. No studies were found that examined surgical outcomes or neurocognitive changes.

CONCLUSION

There is little information to guide TMGD individuals who are considering TH/BSO versus TH/BS with ovarian retention. Our review suggests that there is limited evidence to suggest that fertility preservation is successful after TH/BS with ovarian retention. Current evidence does not support regular reduction in testosterone dosing following oophorectomy. Estradiol levels are likely higher in individuals that choose ovarian retention, but this has not been clearly demonstrated. Although bone mineral density decreases following oophorectomy, data demonstrating an increased fracture risk are lacking. No studies have described the specific impact on neurocognitive function, or changes in operative complications. Further research evaluating long-term health outcomes of oophorectomy for TMGD individuals treated with chronic testosterone therapy is warranted to provide comprehensive, evidence-based healthcare to this patient population. Sahil Kumar, Smita Mukherjee, Cormac O'Dwyer, et al. Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review. Sex Med Rev 2022;10:636-647.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Similar fertilization rates and preimplantation embryo development among testosterone-treated transgender men and cisgender women

RESEARCH QUESTION

What are the effects of testosterone treatment on oocyte fertilization and preimplantation embryo development among transgender men who have undergone fertility preservation?

DESIGN

A retrospective study was undertaken in a university-affiliated tertiary hospital between April 2016 and November 2021. Embryos were divided into three groups by source: 210 embryos from 7 testosterone-exposed transgender men, 135 from 10 cisgender women who cryopreserved embryos, and 276 from 24 cisgender women who underwent fertility treatment. Statistical analyses compared assisted reproductive technology outcomes between the group of transgender men and both groups of cisgender women. Morphokinetic and morphological parameters were compared between the embryos derived from these three groups.

RESULTS

The transgender men (30.2 ± 3.5 years of age) were significantly younger than the cisgender women who cryopreserved embryos (35.1 ± 1.8 years; P = 0.005) and the cisgender women who underwent fertility treatment (33.8 ± 3.2 years; P = 0.017). After adjusting for participant age, the fertilization rate was comparable between the transgender men and both groups of cisgender women (P = 0.391 and 0.659). There were no significant differences between the transgender men and the cisgender women who preserved fertility in terms of number of cryopreserved embryos (7.2 ± 5.1 and 3.5 ± 2.6; P = 0.473) or the distribution of embryo age at cryopreservation (P = 0.576). All morphokinetic parameters evaluated by time-lapse imaging, as well as the morphological characteristics, were comparable for the embryos in all three groups.

CONCLUSIONS

Testosterone exposure among transgender men has no adverse impact upon fertilization rates or preimplantation embryo development and quality.

Mapping Accessibility to Fertility Preservation for Trans Masculine Individuals in The Netherlands

Purpose: Since 2014 in The Netherlands, sterilization is no longer required for legal gender affirmation. Access to fertility preservation (FP) options is indispensable to grant equal reproductive rights to this population. This study aims to map existing literature on barriers and enabling factors for trans masculine individuals to access FP in The Netherlands after 2014. Methods: A scoping review method was conducted, including a database and a hand search complemented with informal consultations. Literature between 2014 and 2021 was searched. Results: A total of 38 peer-reviewed articles and 22 complementary gray literature sources were retrieved. Thematic analysis identified seven common themes: biological, psychological, training, language, law and legislation, economic, and sociocultural. The themes were clustered as patient-, health care provider (HCP)- and environment-related. Conclusion: The Netherlands offers progressive legislation and accommodating insurance agreements that favor FP for trans masculine individuals. However, the current readiness of HCPs to provide adapted and tailored care is arguable, and the capacity to access appropriate health services for trans masculine individuals is largely nonexistent outside of highly specialized health institutions. The implementation of both formal and informal education training programs for HCPs on transgender and gender diverse health needs-as well as inclusive language use-could benefit this community at large.

Fertility preservation in transgender and non-binary adolescents and young adults

Although 37.5-51% of transgender adults state they would've considered freezing gametes before gender-affirming therapy if offered and 24-25.8% of transgender adolescents express interest in having biological children, less than 5% of transgender adolescents have opted for fertility preservation. We sought to assess fertility preservation utilization in our multidisciplinary adolescent gender clinic. We also aimed to identify fertility preservation utilization and interest among non-binary adolescents and young adults. A retrospective review was conducted of patients seen in the Stanford Pediatric & Adolescent Gender Clinic from October 2015 through March 2019 who were >10 years of age at initial visit. All individuals with documented discussion of fertility preservation were offered referral for formal fertility preservation consultation but only 24% of patients accepted. Only 6.8% of individuals subsequently underwent fertility preservation (n = 9). Transfeminine adolescents are more likely to pursue fertility preservation than transmasculine adolescents (p = 0.01). The rate of fertility preservation in non-binary adolescents did not significantly differ from those in transfeminine adolescents (p = 1.00) or transmasculine adolescents (p = 0.31). Although only one non-binary individual underwent fertility preservation, several more expressed interest with 36% accepting referral (n = 4) and 27% being seen in consultation (n = 3). Despite offering fertility preservation with designated members of a gender clinic team, utilization remains low in transgender adolescents. Additionally, non-binary adolescents and their families are interested in fertility preservation and referrals should be offered to these individuals. Further studies and advocacy are required to continue to address fertility needs of transgender adolescents.

Reproductive health in transgender and gender diverse individuals: A narrative review to guide clinical care and international guidelines

Background

Hormonal treatments and surgical interventions practiced with the aim to affirm gender identity in transgender and gender diverse patients may impact their future reproductive ability, family building, and family planning options. Whereas it is recommended by international guidelines to discuss the potential risks of infertility and to present fertility preservation (FP) options to transgender individuals and their families prior to initiating any of these treatments, many barriers still remain. Further, transgender and gender diverse individuals often experience barriers to accessing contraception, abortion, pre-conception care, and comprehensive perinatal care.

Aims

In this review we summarize the current literature on reproductive healthcare issues reported in transgender people including fertility issues, fertility preservation (FP), contraception, pregnancy and lactation and perinatal health.

Methods

A narrative literature search of major databases (Pubmed, Medline, PsycInfo, Google Scholar, Web of Science) was conducted. Given the paucity and heterogeneity of studies, summative review tactics were not available. The literature was critically reviewed by international experts in the field with focus on the impact of gender-affirming medical interventions on future fertility, current FP options and reproductive health issues in transgender people.

Results

The current literature supports that transgender and gender diverse individuals may wish to have genetically related children in the future, rendering the issue of FP relevant to this patient group. The cryopreservation of mature gametes is an efficacious option for FP for post-pubertal adolescents and adults. It is recommended to discuss these options at time of planning for gender-affirming hormonal therapy (GAHT) or engaging with other gender-affirming procedures that can limit future fertility. Discontinuation of GAHT may allow individuals to undergo FP later, but data are limited and there is the concern of symptoms and consequences of stopping GAHT. For pre-pubertal and early pubertal children, FP options are limited to the cryopreservation of gonadal tissue. At present the tissue can become functional only after re-transplantation, which might be undesirable by transgender individuals in the future. Preconception counseling, prenatal surveillance, perinatal support, contraceptive, and pregnancy termination related healthcare need to be meaningfully adapted for this patient population, and many knowledge gaps remain.

Discussion

Specialized FP reproductive healthcare for transgender and gender diverse individuals is in early evolution. Research should be conducted to examine effects of medical interventions on fertility, timing of FP, gamete preservation and outcome of the fertility treatments. Strategies to inform and educate transgender and gender diverse patients can lead to optimization of reproductive care and counseling and decision making of FP for this population.

Comparison between slow freezing and vitrification of ovarian tissue cryopreservation in assigned female at birth transgender people receiving testosterone therapy: data on histological and viability parameters

PURPOSE

The use of fertility preservation (FP) techniques has significantly increased in recent years in the assigned female at birth (AFAB) transgender population. Oocyte cryopreservation is the established method for FP, but ovarian tissue cryopreservation may be considered an alternative option, especially during gender-affirming surgery (GAS). The slow freezing (SF) cryopreservation technique is the standard method for human ovarian tissue, but recently, several studies have shown good results with the vitrification (VT) technique. The objective of this study was to compare the effectiveness of VT and SF techniques in ovarian tissue from AFAB transgender people.

METHODS

This was a prospective study including 18 AFAB transgender people after GAS. Ovarian tissue pieces from each ovary were cryopreserved by SF and VT and compared with fresh tissue. Study by light microscopy (LM) assessed follicular morphology and density. The percentage of surviving and degenerated follicles was studied with the tissue viability test. Oocytes, granulosa cells and stroma were analysed separately by transmission electron microscopy.

RESULTS

The VT technique preserves follicle and stromal tissue as well as the SF method, but with some differences. Evaluation by LM showed better follicle preservation with VT, but the ultrastructural study showed the presence of minor damage with both techniques compared to fresh tissue.

CONCLUSION

Both cryopreservation techniques are accurate for maintaining the follicular population and stromal tissue. Further studies are needed to determine the impact of VT on ovarian tissue and the subsequent follicular activation mechanisms in AFAB ovarian tissue.

In Vitro Maturation of Oocytes Retrieved from Ovarian Tissue: Outcomes from Current Approaches and Future Perspectives

In vitro maturation (IVM) of transvaginally aspirated immature oocytes is an effective and safe assisted reproductive treatment for predicted or high responder patients. Currently, immature oocytes are also being collected from the contralateral ovary during laparoscopy/laparotomy and even ex vivo from the excised ovary or the spent media during ovarian tissue preparation prior to ovarian cortex cryopreservation. The first live births from in vitro-matured ovarian tissue oocytes (OTO-IVM) were reported after monophasic OTO-IVM, showing the ability to achieve mature OTO-IVM oocytes. However, fertilisations rates and further embryological developmental capacity appeared impaired. The introduction of a biphasic IVM, also called capacitation (CAPA)-IVM, has been a significant improvement of the oocytes maturation protocol. However, evidence on OTO-IVM is still scarce and validation of the first results is of utmost importance to confirm reproducibility, including the follow-up of OTO-IVM children. Differences between IVM and OTO-IVM should be well understood to provide realistic expectations to patients.

Beyond the Binary: Sexual and Reproductive Health Considerations for Transgender and Gender Expansive Adolescents

Awareness and visibility of transgender individuals have grown exponentially. However, conceptualizing sexual and reproductive health (SRH) as “women's” or “men's” health services further marginalizes transgender and gender-expansive (TGE) youth. Multiple reviews and commentaries have been published on the topic of SRH care for adults under the umbrella term of sexual and gender minorities, all with a call to action for more inclusive care and the need for more clinical research involving TGE individuals, and notably, TGE youth. Results from adult TGE studies are often translated to describe adolescent models. However, models specific to adolescent TGE populations are needed to understand their unique SRH needs. This review will describe the current literature relating to SRH needs of TGE youth and adults, highlighting key areas with significant disparities in need of further research. This comprehensive summary will also provide recommendations for clinicians and researchers with the goal of improving SRH care and obtaining wider representation in both clinical settings and research directed toward TGE youth.

Histologic Findings in Gynecologic Tissue From Transmasculine Individuals Undergoing Gender-Affirming Surgery

CONTEXT.—

Gender-affirming surgery is part of a multidisciplinary approach in gender transitioning. Deeper histologic examination may strengthen care for transmasculine individuals and increase the understanding of the influence of hormonal therapy in specific organs.

OBJECTIVE.—

To evaluate and catalogue histologic findings of tissue obtained from gender-affirming gynecologic surgery and cervical cytology specimens.

DESIGN.—

This is an institutional review board-approved retrospective study that included transmasculine individuals who underwent gender-affirming gynecologic surgery from January 2015 to June 2020. All surgical gynecologic pathology and cervical cytology slides were reviewed by 2 pathologists.

RESULTS.—

Fifty-five patients were included, which represented 40 uteri, 35 bilateral ovaries, 15 vaginectomy specimens, and 24 cervical cytology results. The median age was 27 years (range, 18-56) and 94% (50 of 53) of patients were receiving testosterone for at least 1 year. Seventy-five percent (30 of 40) of endometria were inactive, while 25% (10 of 40) showed evidence of cycling. Transitional cell metaplasia was the most common finding in the cervix (17 of 40) and vagina (15 of 15), reflecting a high percentage (4 of 24) of unsatisfactory or ASC-US (atypical squamous cells of undetermined significance) cervical cytologies. Prostatic-type glands were identified in 20% (8 of 40) of cervices and 67% (10 of 15) of vaginectomy specimens. Multiple bilateral cystic follicles and evidence of follicular maturation were present in 57% (20 of 35) of cases. Four cases showed paratubal epididymis-like mesonephric remnant hypertrophy.

CONCLUSIONS.—

A comprehensive evaluation of tissue from gender-affirming surgery increases knowledge of the changes following androgen therapy in transmasculine individuals and may contribute to optimal patient care by raising awareness of normal histologic variations in this population.

Reproductive potential and fertility preservation in transgender and nonbinary individuals

PURPOSE OF REVIEW

To synthesize recent literature to better understand parenting desires and challenges of transgender individuals as well as the impact of gender-affirming care on reproductive potential.

RECENT FINDINGS

Survey studies of transgender and nonbinary individuals demonstrate significant parenting interest, yet uptake in fertility preservation services remains low with potential for decisional regret. Masculinizing hormones have demonstrated variable effects on folliculogenesis and follicle distribution in the human ovary. In the mouse model, testosterone administration has demonstrated an increase in atretic late antral follicles without a reduction in primordial or total antral follicle counts and a preserved ability to respond to gonadotropin stimulation. Case series of transgender individuals undergoing oocyte or embryo cryopreservation are promising with outcomes similar to cisgender controls. Feminizing hormones have shown detrimental effects on sperm parameters at time of cryopreservation and spermatogenesis in orchiectomy samples with uncertainty regarding the reversibility of these changes.

SUMMARY

Current evidence demonstrates variable effects of gender-affirming hormones on ovarian and testicular function with potential for detrimental impact on an individual's reproductive potential. As many individuals initiate gender-affirming care prior to or during their reproductive years it is imperative that they receive thorough fertility preservation counseling and improved access to reproductive care services.

Live births following fertility preservation using in-vitro maturation of ovarian tissue oocytes

STUDY QUESTION

Can oocytes extracted from excised ovarian tissue and matured in vitro be a useful adjunct for urgent fertility preservation (FP)?

SUMMARY ANSWER

Ovarian tissue oocyte in-vitro maturation (OTO-IVM) in combination with ovarian tissue cryopreservation (OTC) is a valuable adjunct technique for FP.

WHAT IS KNOWN ALREADY

Despite the impressive progress in the field, options for FP for cancer patients are still limited and, depending on the technique, clinical outcome data are still scarce.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study conducted at a university hospital-affiliated fertility clinic between January 2012 and May 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study included 77 patients who underwent unilateral oophorectomy for OTC. Cumulus-oocyte complexes (COCs) obtained during ovarian tissue processing were matured in vitro for 28-42 h. Oocytes reaching metaphase II stage were vitrified or inseminated for embryo vitrification.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, 1220 COCs were collected. The mean oocyte maturation rate was 39% ± 23% (SD). There were 64 patients who had vitrification of oocytes (6.7 ± 6.3 oocytes per patient). There were 13 patients who had ICSI of mature oocytes after IVM, with 2.0 ± 2.0 embryos vitrified per patient. Twelve patients have returned to the clinic with a desire for pregnancy. For seven of these, OTO-IVM material was thawed. Two patients had OTO-IVM oocytes warmed, with survival rates of 86% and 60%. After ICSI, six oocytes were fertilised in total, generating three good quality embryos for transfer, leading to a healthy live birth for one patient. In five patients, for whom a mean of 2.0 ± 0.8 (SD) embryos had been vitrified, seven embryos were warmed in total: one embryo did not survive the warming process; two tested genetically unsuitable for transfer; and four were transferred in separate cycles to three different patients, resulting in two healthy babies. In this small series, the live birth rate per patient after OTO-IVM, ICSI and embryo transfer was 43%.

LIMITATIONS, REASONS FOR CAUTION

The retrospective study design and the limited sample size should be considered when interpreting results.

WIDER IMPLICATIONS OF THE FINDINGS

The results of the study illustrate the added value of OTO-IVM in combination with OTC. We report the first live birth following the use of this appended technique combined with oocyte vitrification.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. M.D.V. reports honoraria for lectures in the last 2 years from MSD and Ferring, outside the submitted work, as well as grant support from MSD. The other authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

Low feasibility of in vitro matured oocytes originating from cumulus complexes found during ovarian tissue preparation at the moment of gender confirmation surgery and during testosterone treatment for fertility preservation in transgender men

OBJECTIVE

To study the feasibility of in vitro maturation of ovarian tissue oocytes for fertility preservation in transgender men on testosterone treatment.

DESIGN

Cross-sectional study SETTING: University hospital PATIENT(S): Eighty-three transgender men enrolled from November 2015 to January 2019 INTERVENTION(S): In vitro maturation of cumulus-oocyte complexes (COCs) harvested at the time of gender confirmation surgery, and fertilization through intracytoplasmic sperm injection.

MAIN OUTCOME MEASURE(S)

In vitro maturation, fertilization, and blastulation rates; comparison of morphokinetics with vitrified-warmed oocytes; and analysis of the genetic profiles of embryos.

SECONDARY OUTCOMES

association between serum hormone levels; COCs' morphologic characteristics, and vitrification rate.

RESULT(S)

All participants were on testosterone treatment for a median of 83 (64[Quartile 1]; 113.2[Quartile 2]) weeks. A total of 1,903 COCs (mean per participant, 23 ± 15.8) were collected. The in vitro maturation rate was 23.8%, vitrification rate was 21.5%, and survival rate after warming was 72.6% (n = 151). Intracytoplasmic sperm injection was performed in 139 oocytes. The rate of normal fertilized oocytes was 34.5%, and 25 (52.1%) embryos reached day 3. One blastocyst was achieved on day 5. Aberrant cleavage patterns and early embryo arrest were observed in 22 (45.8%) and 44 (91.7%) zygotes, respectively. Compared with vitrified-warmed donor oocytes, a delay was observed in pronuclei disappearance, t2 (time to reach 2 cell stage) timings, and CC1 (the duration of the 1st cell cycle) and SS3 (synchronization of cleavage pattern (calculated as t8-t5) time intervals. A normal genetic pattern was seen in 42% embryos. The proportion of vitrified oocytes was negatively associated with progesterone (odds ratio, 0.76) and positively associated with antimüllerian hormone serum levels (odds ratio, 1.23). The highest vitrification rate was achieved by the morphologic characteristic 344 at day 0 and by 433 at day 2.

CONCLUSION(S)

Ovarian tissue oocytes matured in vitro show low developmental capacity in transgender men, when collected under testosterone treatment.

Systematic review of fertility preservation options in transgender patients: a guide for plastic surgeons

Transgender patients often desire to have biological children. However, their reproductive potential is often negatively impacted by gender affirming surgery (GAS) such as gender confirmation surgery (bottom surgery) and medical hormone therapy. Therefore, counselling patients on fertility preservation options before initiating gender-affirming treatments is prudent to avoid reducing their reproductive potential. A systematic review of English, Spanish, Chinese, French and Turkish languages from 2000 to December 23rd, 2019, using the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines, was conducted. The search strategy was designed and conducted by an experienced librarian with input from the study's principle investigator. Fifteen articles that report outcomes of fertility preservation options in transgenders were included. Eight articles described options for transgender women, six reported options for transgender men and one included both transgender women and transgender men. Semen cryopreservation and oocyte cryopreservation are the most common and available methods for fertility preservation in transgenders. Physician awareness of fertility preservation options in transgender patients is crucial to ensure informed discussions regarding reproductive options in the early phase of transition.

Short-term testosterone use in female mice does not impair fertilizability of eggs: implications for the fertility care of transgender males

STUDY QUESTION

Does testosterone use in females affect reproductive potential, particularly with regard to the production of fertilizable gametes?

SUMMARY ANSWER

Testosterone (T) injections given to post-pubertal female mice caused virilization and although the ovaries were smaller than controls they were still responsive and produced fertilizable eggs when superovulated.

WHAT IS KNOWN ALREADY

Studies to examine the effects of testosterone on reproductive potential in transgender males are lacking. Recently, a model was developed that simulates many aspects of testosterone use in transgender males in order to look at reproductive effects of testosterone in female mice. This study found masculinizing effects on the mice but did not find significant deficits on the number of ovarian follicles; however, effects of testosterone use on ovarian stimulation and fertilizability of oocytes were not investigated.

STUDY DESIGN, SIZE, DURATION

A total of 66, 6-week-old Hsd:NSA (CF-1) female mice and six Hsd:ICR (CD-1) male mice were used for this study. Mice were injected s.c. with 400 µg T or sesame oil once a week for 6 weeks and were either killed 1 week after the sixth injection (active exposure group), or 6-7 weeks after the final T injection (washout group).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Both active exposure and washout groups were further subdivided into three groups: unstimulated, equine CG (eCG)-stimulated or eCG/hCG-stimulated. eCG-stimulated mice were killed 44-48 h after eCG injection. eCG/hCG-stimulated mice were injected with eCG, followed 48 h later with hCG. Mice were killed ∼13-18 h after the hCG injection. Data collected included daily vaginal cytology, terminal testosterone levels, ovary weights and histology, number of oocytes/eggs collected in each group, and cleavage to the two-cell stage following IVF.

MAIN RESULTS AND THE ROLE OF CHANCE

Testosterone-treated mice had testosterone levels elevated to the level of male mice and ceased cycling. Ovaries were significantly smaller in testosterone-treated mice, but they contained normal cohorts of follicles and responded to gonadotrophin stimulation by ovulating similar numbers of eggs as controls, that fertilized and cleaved in vitro.

LIMITATIONS, REASONS FOR CAUTION

Mice were treated for only 6 weeks, whereas many transgender men use testosterone for many years before considering biological children, and developmental competence was not assessed. Importantly, a mouse system may not perfectly simulate human reproductive physiology.

WIDER IMPLICATIONS OF THE FINDINGS

The current standard of care for transgender men who desire biological children is to cease testosterone therapy prior to ovarian stimulation, but the necessity for stopping testosterone is not known. Our model demonstrates that it is possible for testosterone-suppressed ovaries to respond to gonadotrophic stimulation by producing and ovulating fertilizable eggs, thereby obviating the need for testosterone cessation prior to ovarian stimulation. In time, these results may provide insights for future clinical trials of fertility treatment options for transgender men.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Reproductive Endocrinology and Infertility fellowship program through UConn Health Graduate Medical Education (to C.B.B.). The authors have no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Fertility preservation options for transgender and gender-nonconforming individuals

PURPOSE OF REVIEW

To provide an overview of the current state of knowledge of fertility risks of gender-affirming therapy, review fertility preservation options for transgender individuals and ways to minimize gender dysphoria during fertility treatment, and identify gaps in knowledge.

RECENT FINDINGS

Recent studies have corroborated older data that gender-affirming hormone therapy creates histopathological changes in the gonads; however, the newer data suggests that some function of the gametes may be preserved. One study in transgender men reported successful in-vitro maturation of testosterone-exposed oocytes with normal spindle structures, and recent studies in transgender women reveal early spermatogenesis in estradiol-exposed testes and some recovery of semen parameters following cessation of hormones. Particular attention has recently been given to fertility preservation in transgender adolescents, revealing unmet informational needs in this population and very few are actually pursuing fertility preservation, even with counseling.

SUMMARY

There is currently a paucity of data on the fertility effects of gender-affirming hormones, necessitating fertility preservation counseling prior to initiation of therapy. Several modifications can be made to fertility preservation protocols and procedures to decrease gender dysphoria or distress in transgender individuals, but outcome data is still lacking. Achieving high-quality data collection will likely require cooperation across multiple institutions.

Ovarian Histopathology in Transmasculine Persons on Testosterone: A Multicenter Case Series

BACKGROUND

As transmasculine persons utilize androgen gender affirming hormone therapy as a part of transition, guidance has been lacking on the effects of the therapy on the ovaries, especially for those who may desire retention.

AIM

To describe the ovarian histopathology of transmasculine persons on testosterone therapy following oophorectomy at the time of hysterectomy performed for gender affirmation.

METHODS

This was a multicenter case series study of transmasculine patients on testosterone therapy who underwent hysterectomy with oophorectomy for gender affirmation between January 2015 and December 2017 at 5 tertiary care referral centers. Patients were identified by their current procedural and International Classification of Diseases codes.

OUTCOMES

Pre-, perioperative, and pathologic data were obtained from the electronic medical records and ovarian tissue descriptions from pathology reports were grouped into the following classifications: (i) simple/follicular cysts; (ii) polycystic ovaries; (iii) complex cysts; (iv) endometriomas; (v) other masses; (vi) atrophy; and (vii) normal.

RESULTS

85 patients were included in the study. At the time of oophorectomy, the mean age and body mass index of the cohort were 30.4 ± 8.4 years and 30.2 ± 7.3 kg/m2, respectively, and the average interval from the initiation of testosterone to oophorectomy was 36 0.3 ± 37.9 months. On examination of ovarian histopathology, 49.4% (42) of specimens were found to have follicular/simple cysts, 5.9% (5) were polycystic, and 38.8% (33) had normal pathology. For those specimens with volume documented (n = 41), the median volume was 9.6 (range 1.5-82.5) cm3. There was no association between the duration of testosterone therapy or body mass index and the presence of cysts in the ovaries.

CLINICAL IMPLICATIONS

The results of this study reported benign histopathology in ovaries of a large cohort of transmasculine persons on testosterone which should be included when counseling patients on ovarian retention, as transmasculine patients may choose to retain their ovaries while on testosterone for a variety of reasons (including no desire to undergo surgery, desire for backup sex steroids, and potential use for future fertility).

STRENGTHS & LIMITATIONS

This is a large multicenter study seeking to address the uncertainty in present counseling surrounding ovarian conservation in transmasculine persons on testosterone therapy. Its limitations included its retrospective nature and inability to address ovarian function after testosterone discontinuance.

CONCLUSION

In this cohort of transmasculine patients on testosterone therapy undergoing hysterectomy with oophorectomy for gender affirmation, ovarian histopathology was benign in all the specimens. Grimstad FW, Fowler KG, New EP, et al. Ovarian Histopathology in Transmasculine Persons on Testosterone: A Multicenter Case Series. J Sex Med 2020;17:1807-1818.

Ethical issues involving fertility preservation for transgender youth

PURPOSE

To investigate ethical issues associated with fertility preservation (FP) in transgender youth based on reports of patients and their parents.

METHODS

Our qualitative study involved in-person interviews with 54 subjects (35 patients and 19 parents). Interviews were audio recorded, transcribed, and verified. Each subject completed a demographic questionnaire, and each patient's medical chart was reviewed for additional information. We analyzed the data using inductive thematic content analysis.

RESULTS

Themes that emerged included a range of desires and ambivalence about having genetically related children, variability in understanding the potentially irreversible impact of gender affirming hormones (GAHs) on fertility, use of adoption, and the impact of age on decision-making. Subjects (patients and parents) noted barriers to FP, such as cost and insurance coverage. Several parents expressed concern that their transgender children may have future regret about not attempting FP. Both transgender youth and their parents felt FP was an important precaution.

CONCLUSIONS

Our study took advantage of the richness of personal narratives to identify ongoing ethical issues associated with fertility preservation in transgender youth. Transgender youth and their parents did not fully understand the process of FP, especially regarding the effects of GAHs, had fears that FP could reactivate gender dysphoria, and noted barriers to FP, such as cost, highlighting economic disparity and lack of justice. These findings highlight ethical issues involving the adequacy of informed consent and economic injustice in access to FP despite expressed interest in the topic.

Ovarian stimulation outcomes among transgender men compared with fertile cisgender women

PURPOSE

To compare assisted reproductive technology (ART) outcomes among transgender men with those of fertile cisgender women.

METHODS

This retrospective cohort study included 12 transgender men, six with no testosterone exposure and six after testosterone treatment, and 12 cisgender women (oocyte donors) who underwent ART in our institution between June 2017 and December 2019. Statistical analyses compared ART data and outcomes between three groups: cisgender women, transgender men without testosterone exposure, and transgender men after testosterone exposure. Comparisons were also made between transgender men with and without testosterone exposure.

RESULTS

The transgender men with no testosterone exposure (23.3 ± 4 years) were significantly younger than the transgender men who had undergone testosterone treatment (30.3 ± 3.8 years; P = 0.012) and the cisgender women (29.1 ± 3.1 years; P = 0.004). The amount of FSH used for ovulation induction (1999 ± 683 mIU/mL) was significantly lower among transgender men without prior testosterone exposure compared with that among cisgender women (3150 ± 487 mIU/mL; P = 0.007). There were no differences in the peak estradiol levels, the number of oocytes retrieved, the number of MII oocytes, and the oocyte maturity rates between the three groups. Five out of six testosterone-treated transgender men underwent embryo cryopreservation, and they all achieved good-quality embryos.

CONCLUSIONS

Transgender men have an excellent response to ovulation stimulation even after long-term exposure to testosterone. Oocyte/embryo cryopreservation is, therefore, a feasible and effective way for them to preserve their fertility for future biological parenting.

Fertility Counseling for Transgender Adolescents: A Review

International guidelines in transgender health recommend fertility counseling before the commencement of puberty suppression, estrogen, or testosterone, given the potential for these treatments to impair fertility. However, these recommendations provide little actual guidance to clinicians. Consequently, differences in knowledge and attitudes may lead to clinicians adopting different approaches and goals in the fertility counseling they provide. This review draws attention to the disparity between the rates of desire for genetic parenthood among transgender individuals and the actual rates of fertility preservation (FP) and examines different factors in fertility counseling that affect clinical practice and contribute to this disparity. These factors include how a lack of strong evidence-for the effects of hormone therapy on future fertility and success rates of some FP options-impacts upon counseling, transgender peoples' experiences of fertility counseling and preservation, consideration of a young person's developmental stage and the roles of parents and clinicians in the decision-making process, considerations shaping transgender adolescents' decisions to preserve fertility, and access barriers to FP. In doing so, this review highlights the complexities and issues that clinicians must consider when providing fertility counseling to transgender adolescents and-in part-helps to address the lack of detailed clinical guidelines in this area.

Fertility preservation in a transgender man without prolonged discontinuation of testosterone: a case report and literature review

Objective

To study the feasibility of fertility preservation in a transgender man without an extended period of androgen cessation.

Design

Report of a foundational case of oocyte cryopreservation in a transgender man without stopping testosterone therapy before controlled ovarian stimulation. We performed a literature review, identifying five publications on oocyte cryopreservation outcomes in transgender men on testosterone.

Setting

A university-affiliated fertility clinic in Canada.

Patient(s)

A 28-year-old transgender man taking testosterone for 3 years requesting oocyte cryopreservation before gender-affirming surgery. He desired to proceed without stopping testosterone. Pretreatment antimüllerian hormone level was 1.89 ng/mL. The patient’s consent was obtained for written publication.

Intervention(s)

Testosterone was stopped for only three doses (immediately before and during ovarian stimulation). A standard antagonist protocol was used with letrozole to minimize estrogenic side effects.

Main Outcome Measure(s)

Number of oocytes retrieved and days off testosterone.

Result(s)

Thirteen oocytes were retrieved; 11 were mature and vitrified. The total time off testosterone was 24 days. In all prior publications, testosterone was stopped for 3–6 months.

Conclusion(s)

Transgender men have traditionally discontinued exogenous testosterone until the resumption of menses (≤6 months). This is known to be distressing. This is the first published case demonstrating the feasibility of ovarian stimulation without prolonged testosterone cessation in a transgender man. Future studies with a larger sample size should be performed to confirm these findings. The short duration off testosterone may improve patient’s experiences, increase treatment acceptability, and decrease gender dysphoria for transgender men considering fertility preservation.

Fertility Preservation for Transgender Individuals: A Review

Transgender individuals represent a small, albeit growing, patient population that is encountered more frequently in clinical care due to improved insurance coverage and increasing awareness. Gender-affirming treatments, including both gender-affirming hormone therapy and gender-affirming surgery, pose significant risks to fertility potential and outcomes, ranging from potentially impaired fertility rates to full elimination of reproductive potential depending on the type of treatment pursued. However, there are relatively limited data specific to fertility preservation for transgender individuals. Current approaches to treatment are extrapolated from options for fertility preservation after oncologic diagnoses. In this review, we aim to summarize current clinical approaches, fertility preservation options, and patient experiences in fertility preservation for transgender individuals. Several forms of fertility preservation options are available depending on the pubertal status of a transgender individual. Despite the multiple options for fertility preservation, major barriers exist to patient care and there are reports of mixed patient experiences. Further awareness of this clinical situation and understanding of these processes will allow for comprehensive and specialized care for transgender individuals who may otherwise miss opportunities for adequate counseling or treatment options regarding fertility preservation.

Impact of Exogenous Testosterone on Reproduction in Transgender Men

Studies show that a subset of transgender men desire children; however, there is a paucity of literature on the effect of gender-affirming testosterone therapy on reproductive function. In this manuscript, we will review the process of gender-affirming hormone therapy for transgender men and what is known about ovarian and uterine consequences of testosterone exposure in transgender men; draw parallels with existing animal models of androgen exposure; summarize the existing literature on parenting experiences and desires in transgender people; discuss considerations for assisted reproductive technologies and fertility preservation; and identify gaps in the literature and opportunities for further research.