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Chan-Sui R, Kruger RE, Cho E, Padmanabhan V, Moravek M, Shikanov A. 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. Reproduction 2024; 168:e240163. [PMID: 39190001 PMCID: PMC11449632 DOI: 10.1530/rep-24-0163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 08/23/2024] [Indexed: 08/28/2024]
Abstract
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.
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Affiliation(s)
- Ruth Chan-Sui
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Robin E. Kruger
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Evelyn Cho
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Vasantha Padmanabhan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan 48109, USA
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor
| | - Molly Moravek
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Urology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ariella Shikanov
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
- Cellular and Molecular Biology Program, University of Michigan, Ann Arbor, MI 48109, USA
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Glodowski MB, Parra CM, Xin MK, Fino ME. Reproductive Considerations in the Transgender and Gender Diverse Population: A Review. Endocrinol Metab Clin North Am 2024; 53:471-482. [PMID: 39084820 DOI: 10.1016/j.ecl.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Many transgender and gender diverse (TGD) individuals will be considering gender-affirming treatments during their reproductive lifespan. These medically necessary treatments have a negative impact on reproductive potential. All TGD individuals should be counseled regarding fertility. Options for fertility preservation for individuals who have undergone puberty include mature oocyte, embryo, and sperm cryopreservation. In prepubertal individuals, ovarian tissue cryopreservation may be considered, but testicular tissue cryopreservation remains experimental only. While there have been advances in the technology and standardization of reproductive health care for this population, many gaps remain in our knowledge which require further research.
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Affiliation(s)
- Michele B Glodowski
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, New York University Langone Health, 111 Broadway, 2nd Floor, New York, NY 10006, USA.
| | - Carlos M Parra
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology, New York University Langone Prelude Fertility Center, 159 East 53rd Street, 3rd Floor, New York, NY 10022, USA
| | - Madeline K Xin
- NYU Grossman School of Medicine, 550 First Avenue, New York, NY 10016, USA
| | - Mary Elizabeth Fino
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology, New York University Langone Prelude Fertility Center, 159 East 53rd Street, 3rd Floor, New York, NY 10022, USA
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Kauffman AS. Androgen Inhibition of Reproductive Neuroendocrine Function in Females and Transgender Males. Endocrinology 2024; 165:bqae113. [PMID: 39207217 PMCID: PMC11393496 DOI: 10.1210/endocr/bqae113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 08/23/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
Ovarian function is controlled by pituitary secretion of luteinizing hormone (LH) and follicle stimulating hormone (FSH), which in turn are governed by gonadotropin releasing hormone (GnRH) secreted from the brain. A fundamental principle of reproductive axis regulation is negative feedback signaling by gonadal sex steroids back to the brain to fine-tune GnRH and gonadotropin secretion. Endogenous negative feedback effects can be mimicked by exogenous steroid treatments, including androgens, in both sexes. Indeed, a growing number of clinical and animal studies indicate that high levels of exogenous androgens, in the typically male physiological range, can inhibit LH secretion in females, as occurs in males. However, the mechanisms by which male-level androgens inhibit GnRH and LH secretion still remain poorly understood, and this knowledge gap is particularly pronounced in transgender men (individuals designated female at birth but identifying as male). Indeed, many transgender men take long-term gender-affirming hormone therapy that mimics male-level testosterone levels. The impact of such gender-affirming testosterone on the reproductive axis, both at the ovarian and neuroendocrine level, is a long-understudied area that still requires further investigation. Importantly, the few concepts of androgen actions in females mostly come from studies of polycystic ovary syndrome, which does not recapitulate a similar androgen milieu or a pathophysiology of inhibited LH secretion as occurs in testosterone-treated transgender men. This review summarizes clinical evidence indicating that exogenous androgens can impair neuroendocrine reproductive function in both female individuals and transgender men and highlights emerging experimental data supporting this in recently developed transgender rodent models.
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Affiliation(s)
- Alexander S Kauffman
- Department of OBGYN and Reproductive Sciences, University of California San Diego, La Jolla, CA 92093, USA
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Cuq J, Lapoirie M, Plotton I, Fraison E, Neuville P, Oriol S. [Transmasculine people: Gender affirming hormonal therapy, sexual and reproductive health prevention and care, a medical review and follow-up suggestions]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024:S2468-7189(24)00263-0. [PMID: 39097191 DOI: 10.1016/j.gofs.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/23/2024] [Accepted: 06/17/2024] [Indexed: 08/05/2024]
Abstract
Transmasculine individuals have a poor access to health care, mostly regarding the sexual and reproductive health. Despite a lack of official guidelines, they need a gynecological follow-up, the aim of this review was to describe it. The present study involved an exhaustive search of MEDLINE, 68 articles were included to analyze the impact of hormonal therapy, prevention, and care regarding sexual and reproductive health of transmasculine individuals. Despite a lack of solid data, the global literature agrees that transmasculine individuals require sexual and reproductive health care. Care must be adapted to each pathway and may be impacted by gender-affirming care. The cancer risk does not seem to be increased in this population, particularly in relation to hormonal therapy. Prevention programs do not differ from those offered to cis women in the absence of gender-affirming surgeries. Transmasculine individuals require follow-up and care adapted to their needs and their pathways. Healthcare professionals must be trained to provide such care.
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Affiliation(s)
- Juliette Cuq
- Hospices civils de Lyon, université Claude-Bernard, Lyon, France.
| | - Marion Lapoirie
- Service de médecine de la reproduction, hôpital Lyon Est, Lyon, France
| | - Ingrid Plotton
- Service de médecine de la reproduction, hôpital Lyon Est, Lyon, France
| | - Eloise Fraison
- Service de médecine de la reproduction, hôpital Lyon Est, Lyon, France
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Ghofranian A, Aharon D, Friedenthal J, Hanley WJ, Lee JA, Daneyko M, Rodriguez Z, Safer JD, Copperman AB. Family Building in Transgender Patients: Modern Strategies with Assisted Reproductive Technology Treatment. Transgend Health 2024; 9:76-82. [PMID: 38312448 PMCID: PMC10835155 DOI: 10.1089/trgh.2021.0210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose Transgender and gender diverse (TGD) individuals continue to face adversity, stigma, and inequality, especially in health care. This study aimed to characterize the experience of TGD people and partners of TGD people with regard to fertility treatment. Methods All TGD patients presenting to a single academic center between 2013 and 2021 were included. Baseline demographics collected included patient age, body mass index, anti-Mullerian hormone, basal antral follicle count, history of gender-affirming surgery, and/or gender-affirming hormone therapy. Outcomes included total patients who progressed to treatment, cycle type(s), and clinical outcomes. Results In total, 82 patients who identified as TGD or had a partner who identified as TGD presented to care seeking fertility treatment. Of the 141 planned cycles, 106 (75.2%) progressed to treatment. Of the 15 in vitro fertilization (IVF) and co-IVF cycles, 12 achieved live birth. Of the 76 intrauterine inseminations 7 patients were discharged with ongoing pregnancies and one achieved live birth. Conclusion These findings reaffirm that TGD individuals utilize the entire array of fertility services. With recent advances in access to care and modern medicine, assisted reproductive technology treatment has the power to support TGD patients in building contemporary family structures.
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Affiliation(s)
- Atoosa Ghofranian
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Devora Aharon
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Reproductive Medicine Associates of New York, New York, New York, USA
| | - Jenna Friedenthal
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Reproductive Medicine Associates of New York, New York, New York, USA
| | - William J. Hanley
- Reproductive Medicine Associates of New York, New York, New York, USA
| | - Joseph A. Lee
- Reproductive Medicine Associates of New York, New York, New York, USA
| | - Margaret Daneyko
- Reproductive Medicine Associates of New York, New York, New York, USA
| | - Zoe Rodriguez
- Mount Sinai Center for Transgender Medicine and Surgery, New York, New York, USA
| | - Joshua D. Safer
- Mount Sinai Center for Transgender Medicine and Surgery, New York, New York, USA
| | - Alan B. Copperman
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Reproductive Medicine Associates of New York, New York, New York, USA
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Ghofranian A, Estevez SL, Gellman C, Gounko D, Lee JA, Thornton K, Copperman AB. Fertility treatment outcomes in transgender men with a history of testosterone therapy. F S Rep 2023; 4:367-374. [PMID: 38204952 PMCID: PMC10774903 DOI: 10.1016/j.xfre.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 01/12/2024] Open
Abstract
Objective To evaluate fertility treatment outcomes among transgender (TG) men with a history of gender-affirming hormone therapy with exogenous testosterone. Design Descriptive, retrospective cohort study. Patients Transgender men with a history of gender-affirming hormone therapy with exogenous testosterone underwent fertility treatments, including embryo cryopreservation, in vitro fertilization (IVF), co-IVF, oocyte cryopreservation, and intrauterine insemination (IUI), between 2013 and 2021. Intervention Gender-affirming hormone therapy with testosterone. Main Outcome Measures Live births (LBs), number of frozen embryos, and number of frozen oocytes. Other outcome measures included total gonadotropin used, peak estradiol levels, oocytes retrieved, oocyte maturity rate, fertilization rate, and embryo grade. Results A total of 77 TG men self-presented or were referred to care at a single academic fertility center, of which 46 (59.7%) TG men underwent fertility preservation and/or family-building counseling, with 16 (20.8%) patients proceeding to fertility treatment. Of those patients who underwent treatment, 11 (68.8%) had a history of gender-affirming hormone therapy with exogenous testosterone use. Cohort 1 included IVF (n = 1), co-IVF (n = 1), embryo cryopreservation (n = 2), cohort 2 included oocyte cryopreservation (n = 4), and cohort 3 included IUI (n = 3). In cohort 1, both the patients who underwent IVF and the patients who underwent co-IVF achieved LBs. All embryo cryopreservation cycles froze three or more embryos. In cohort 2, the average number of frozen mature oocytes was 19.3 ± 16.2 (range 6-43). All patients who underwent IUI cycles achieved LB. Conclusion In this study, no correlation existed between patient age, time on or off gender-affirming hormone therapy with exogenous testosterone, total gonadotropin used, and number of oocytes retrieved. All patients who completed IVF or embryo cryopreservation produced high-quality blastocytes, and this is the first study to show successful IUI cycles in patients with a history of gender-affirming hormone therapy with exogenous testosterone. This study demonstrates that TG men who have used gender-affirming hormone therapy previously can successfully undergo fertility treatments to attain oocyte and embryo cryopreservation, pregnancy, and LBs.
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Affiliation(s)
- Atoosa Ghofranian
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
- Reproductive Medicine Associates of New York, New York, New York
| | - Samantha L. Estevez
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
- Reproductive Medicine Associates of New York, New York, New York
| | - Caroline Gellman
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dmitry Gounko
- Reproductive Medicine Associates of New York, New York, New York
| | - Joseph A. Lee
- Reproductive Medicine Associates of New York, New York, New York
| | - Kimberly Thornton
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
- Reproductive Medicine Associates of New York, New York, New York
| | - Alan B. Copperman
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
- Reproductive Medicine Associates of New York, New York, New York
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Chabbert-Buffet N, Sermondade N, Moreau E, Cristofari S, Johnson N, Mathieu d'Argent E, Levy R, Dupont C. [Transition, fertility and options for preservation of fertility]. ANN CHIR PLAST ESTH 2023; 68:484-490. [PMID: 37423825 DOI: 10.1016/j.anplas.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
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.
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Affiliation(s)
- N Chabbert-Buffet
- Centre de fertilité Tenon, hôpital Tenon, Sorbonne université, AP-HP, Paris, France.
| | - N Sermondade
- Centre de fertilité Tenon, hôpital Tenon, Sorbonne université, AP-HP, Paris, France
| | - E Moreau
- Centre de fertilité Tenon, hôpital Tenon, Sorbonne université, AP-HP, Paris, France
| | - S Cristofari
- Centre de fertilité Tenon, hôpital Tenon, Sorbonne université, AP-HP, Paris, France
| | - N Johnson
- Centre de fertilité Tenon, hôpital Tenon, Sorbonne université, AP-HP, Paris, France
| | - E Mathieu d'Argent
- Centre de fertilité Tenon, hôpital Tenon, Sorbonne université, AP-HP, Paris, France
| | - R Levy
- Centre de fertilité Tenon, hôpital Tenon, Sorbonne université, AP-HP, Paris, France
| | - C Dupont
- Centre de fertilité Tenon, hôpital Tenon, Sorbonne université, AP-HP, Paris, France
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Kinnear HM, Moravek MB. Reproductive capacity after gender-affirming testosterone therapy. Hum Reprod 2023; 38:1872-1880. [PMID: 37573140 PMCID: PMC10546082 DOI: 10.1093/humrep/dead158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/11/2023] [Indexed: 08/14/2023] Open
Abstract
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.
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Affiliation(s)
- Hadrian M Kinnear
- Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI, USA
- Medical Scientist Training Program, University of Michigan, Ann Arbor, MI, USA
| | - Molly B Moravek
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
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Barrero JA, Mockus I. Preservation of Fertility in Transgender Men on Long-Term Testosterone Therapy: A Systematic Review of Oocyte Retrieval Outcomes During and After Exogenous Androgen Exposure. Transgend Health 2023; 8:408-419. [PMID: 37810944 PMCID: PMC10551752 DOI: 10.1089/trgh.2022.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Jorge A. Barrero
- Lipids and Diabetes Division, Department of Physiological Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Ismena Mockus
- Lipids and Diabetes Division, Department of Physiological Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
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Schwartz AR, Xu M, Henderson NC, Dela Cruz C, Pfau D, Padmanabhan V, Shikanov A, Moravek MB. Impaired in vitro fertilization outcomes following testosterone treatment improve with washout in a mouse model of gender-affirming hormone treatment. Am J Obstet Gynecol 2023; 229:419.e1-419.e10. [PMID: 37453652 PMCID: PMC10654792 DOI: 10.1016/j.ajog.2023.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/22/2023] [Accepted: 07/09/2023] [Indexed: 07/18/2023]
Abstract
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.
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Affiliation(s)
- Amanda R Schwartz
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
| | - Min Xu
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Nicholas C Henderson
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Cynthia Dela Cruz
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Daniel Pfau
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | | | - Ariella Shikanov
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Molly B Moravek
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
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11
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Stolk THR, van den Boogaard E, Huirne JAF, van Mello NM. Fertility counseling guide for transgender and gender diverse people. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2023; 24:361-367. [PMID: 37901065 PMCID: PMC10601500 DOI: 10.1080/26895269.2023.2257062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Affiliation(s)
- T. H. R. Stolk
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - E. van den Boogaard
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - J. A. F. Huirne
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - N. M. van Mello
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
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12
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Asseler JD, Knieriem J, Huirne JA, Goddijn M, Verhoeven MO, van Mello NM. Outcomes of oocyte vitrification in trans masculine individuals. Reprod Biomed Online 2023; 47:94-101. [PMID: 37095040 DOI: 10.1016/j.rbmo.2023.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/17/2023] [Accepted: 03/08/2023] [Indexed: 03/16/2023]
Abstract
RESEARCH QUESTION What are the outcomes and experiences of oocyte vitrification treatment in trans masculine individuals (TMI) before and after testosterone use? DESIGN This retrospective cohort study was conducted at the Amsterdam UMC in the Netherlands between January 2017 and June 2021. The TMI who had completed an oocyte vitrification treatment were consecutively approached for participation. Informed consent was provided by 24 individuals. Participants (n = 7) who initiated testosterone therapy were advised to stop 3 months before stimulation. Demographic characteristics and oocyte vitrification treatment data were retrieved from medical records. Evaluation of the treatment was collected via an online questionnaire. RESULTS The median age of participants was 22.3 years (interquartile range 21.1-26.0) and mean body mass index was 23.0 kg/m2 (SD 3.2). After ovarian hyperstimulation, a mean of 20 oocytes (SD 7) were retrieved and a mean of 17 oocytes (SD 6) could be vitrified. Aside from a lower cumulative FSH dose, there were no significant differences between the prior testosterone users and testosterone naïve TMI. The overall satisfaction of oocyte vitrification treatment in participants was high. Hormone injections were considered the most strenuous part of treatment by 29% of participants, closely followed by oocyte retrieval (25%). CONCLUSIONS No difference in response to ovarian stimulation was found for oocyte vitrification treatment between the prior testosterone users and testosterone naïve TMI. The questionnaire identified hormone injections as the most burdensome aspect of oocyte vitrification treatment. This information can be used to improve gender sensitive fertility counselling and fertility treatment strategies.
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Affiliation(s)
- Joyce D Asseler
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands.; Amsterdam UMC, Centre of Expertise on Gender Dysphoria, Amsterdam, The Netherlands.; Amsterdam Reproduction and Development research institute, Amsterdam, The Netherlands..
| | - Julie Knieriem
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Judith Af Huirne
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands.; Amsterdam Reproduction and Development research institute, Amsterdam, The Netherlands
| | - Mariette Goddijn
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynaecology, Meibergdreef 9, Amsterdam, The Netherlands.; Amsterdam Reproduction and Development research institute, Amsterdam, The Netherlands
| | - Marieke O Verhoeven
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands.; Amsterdam Reproduction and Development research institute, Amsterdam, The Netherlands
| | - Norah M van Mello
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands.; Amsterdam UMC, Centre of Expertise on Gender Dysphoria, Amsterdam, The Netherlands.; Amsterdam Reproduction and Development research institute, Amsterdam, The Netherlands
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13
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Reckhow J, Kula H, Babayev S. Fertility preservation options for transgender and nonbinary individuals. Ther Adv Endocrinol Metab 2023; 14:20420188231178371. [PMID: 37323161 PMCID: PMC10265329 DOI: 10.1177/20420188231178371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 05/09/2023] [Indexed: 06/17/2023] Open
Abstract
Transgender and nonbinary individuals are historically underserved by healthcare systems. A crucial area for improvement is fertility preservation counseling and service delivery, as gender-affirming hormone therapy and gender-affirming surgery may negatively affect future fertility. The methods available for fertility preservation depend on the patient's pubertal status and utilization of gender-affirming therapies, and counseling and delivery of these services are complex and require a multidisciplinary approach. Further research is needed to identify pertinent stakeholders in managing the care of these patients, as well as to better understand the optimal frameworks for delivering integrated and comprehensive care to this patient population. Fertility preservation is an active and exciting area of scientific discovery and offers a wealth of opportunities to improve the care of transgender and nonbinary individuals.
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Affiliation(s)
| | - Hakan Kula
- Obstetrics & Gynecology, Dokuz Eylul University, Izmir, Turkey
| | - Samir Babayev
- Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
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14
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Kinnear HM, Hashim PH, Dela Cruz C, Chang AL, Rubenstein G, Nimmagadda L, Ramamoorthi Elangovan V, Jones A, Brunette MA, Hannum DF, Li JZ, Padmanabhan V, Moravek MB, Shikanov A. Presence of ovarian stromal aberrations after cessation of testosterone therapy in a transgender mouse model†. Biol Reprod 2023; 108:802-813. [PMID: 36790125 PMCID: PMC10183359 DOI: 10.1093/biolre/ioad019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/25/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
Some transmasculine individuals may be interested in pausing gender-affirming testosterone therapy and carrying a pregnancy. The ovarian impact of taking and pausing testosterone is not completely understood. The objective of this study was to utilize a mouse model mimicking transmasculine testosterone therapy to characterize the ovarian dynamics following testosterone cessation. We injected postpubertal 9-10-week-old female C57BL/6N mice once weekly with 0.9 mg of testosterone enanthate or a vehicle control for 6 weeks. All testosterone-treated mice stopped cycling and demonstrated persistent diestrus within 1 week of starting testosterone, while control mice cycled regularly. After 6 weeks of testosterone therapy, one group of testosterone-treated mice and age-matched vehicle-treated diestrus controls were sacrificed. Another group of testosterone-treated mice were maintained after stopping testosterone therapy and were sacrificed in diestrus four cycles after the resumption of cyclicity along with age-matched vehicle-treated controls. Ovarian histological analysis revealed stromal changes with clusters of large round cells in the post testosterone group as compared to both age-matched controls and mice at 6 weeks on testosterone. These clusters exhibited periodic acid-Schiff staining, which has been previously reported in multinucleated macrophages in aging mouse ovaries. Notably, many of these cells also demonstrated positive staining for macrophage markers CD68 and CD11b. Ovarian ribonucleic acid-sequencing found upregulation of immune pathways post testosterone as compared to age-matched controls and ovaries at 6 weeks on testosterone. Although functional significance remains unknown, further attention to the ovarian stroma may be relevant for transmasculine people interested in pausing testosterone to carry a pregnancy.
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Affiliation(s)
- Hadrian M Kinnear
- Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI, USA
- Medical Scientist Training Program, University of Michigan, Ann Arbor, MI, USA
| | - Prianka H Hashim
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Cynthia Dela Cruz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Alexis L Chang
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Gillian Rubenstein
- Women’s and Gender Studies Department, University of Michigan, Ann Arbor, MI, USA
| | - Likitha Nimmagadda
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | | | - Andrea Jones
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Margaret A Brunette
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - D Ford Hannum
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Jun Z Li
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Vasantha Padmanabhan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Molly B Moravek
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Division of Reproductive Endocrinology and Infertility, University of Michigan, Ann Arbor, MI, USA
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Ariella Shikanov
- Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
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15
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Conflitti AC, Spaziani M, Pallotti F, Tarsitano MG, Di Nisio A, Paoli D, Lombardo F. Update on bioethical, medical and fertility issues in gender incongruence during transition age. J Endocrinol Invest 2023:10.1007/s40618-023-02077-5. [PMID: 37071372 PMCID: PMC10371879 DOI: 10.1007/s40618-023-02077-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/22/2023] [Indexed: 04/19/2023]
Abstract
PURPOSE Many issues still remain unresolved in the management of pubertal patients with gender incongruence (GI). The aim of this review is to discuss the main aspects of the treatment of these patients to provide a practical approach for clinicians. METHODS A comprehensive literature search within PubMed was performed to provide updates of available evidence regarding the impact on bioethical, medical and fertility issues in gender incongruence during transition age. RESULTS Gender Affirming Hormone Treatment (GAHT) and Gender Affirming Surgery (GAS) can induce unsatisfaction with change, future regrets, and the risk of infertility. This raises ethical issues especially in the management of pubertal patients that remain unresolved. Therapy with GnRH analogues (GnRHa) is intended to delay puberty, so as to give the adolescent a longer period of time to decide whether to continue with the treatments. At the level of physical changes, this therapy may have an effect on bone mineralization and body composition; however, long-term longitudinal data are not yet available. An important feature related to the use of GnRHa is the risk of fertility. Gamete cryopreservation is the most established method of fertility preservation (FP) and should be counselled to transgender adolescents. However, these patients are not always interested in having biological children. CONCLUSION Based on the current evidence, there is a need to conduct further research to clarify certain issues and to standardize clinical practice and improve counselling in transgender adolescent decision making and avoid regrets in the future.
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Affiliation(s)
- A C Conflitti
- Laboratory of Seminology-Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - M Spaziani
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Viale del Policlinico 155, 00161, Rome, Italy
| | - F Pallotti
- Laboratory of Seminology-Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - M G Tarsitano
- Department of Medical and Surgical Science, University Magna Graecia, Catanzaro, Italy
| | - A Di Nisio
- Department of Medicine, Operative Unit of Andrology and Medicine of Human Reproduction, University of Padova, Padua, Italy
| | - D Paoli
- Laboratory of Seminology-Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - F Lombardo
- Laboratory of Seminology-Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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16
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Albar M, Koziarz A, McMahon E, Chan C, Liu K. Timing of testosterone discontinuation and assisted reproductive technology outcomes in transgender patients: a cohort study. F S Rep 2023; 4:55-60. [PMID: 36959967 PMCID: PMC10028470 DOI: 10.1016/j.xfre.2023.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
Objective To determine if there is an association between the timing of testosterone discontinuation and assisted reproductive technology (ART) outcomes. Design Retrospectivse cohort study. Setting Single academic center. Patients We included consecutive transgender patients seeking fertility preservation between October 2019 and April 2021. Patients who identified as transgender on androgens for >1 month on presentation were included. Interventions None. Main outcome measures A linear regression model was used to evaluate the effect of testosterone discontinuation duration on the number of mature oocytes retrieved. Results Eighteen patients (mean age 27.7 [SD 5.2] years, mean body mass index 27.3 [SD 4.6] kg/m2, mean antimüllerian hormone 27.2 [SD 11.8], median antral follicle count 20 [interquartile range (IQR) 14-32]) were included in the analysis. No patient underwent transition-related surgery (eg, oophorectomy, hysterectomy). None of the patients were previously pregnant. Mean time o,n testosterone was 44 (SD 29.6) months. The median time off testosterone until the start of ovarian stimulation was 7.7 weeks (IQR 4.3-20.7). All patients underwent oocyte cryopreservation except one who had embryo cryopreservation. The median total number of oocytes was 11 (IQR 7-14). The median number of mature oocytes was 7.5 (IQR 5-12) oocytes. The univariate regression model evaluating the duration of time off testosterone before ART demonstrated no significant association with the outcome of mature oocytes (regression coefficient, 0.19; 95% confidence interval, -0.13 to 0.50). Conclusion In a retrospective analysis of transgender patients recently on testosterone undergoing ART, no association was detected between the timing of testosterone cessation and the number of mature oocytes.
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Affiliation(s)
- Mohammad Albar
- Department of Obstetrics and Gynaecology, University of King Abdulaziz, Jeddah, Saudi Arabia
| | - Alex Koziarz
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Eileen McMahon
- Hannam Fertility Centre, Toronto, Ontario, Canada
- Bloomberg Faculty of Nursing, University of Toronto, Ontario, Canada
| | - Crystal Chan
- Markham Fertility Centre, Toronto, Ontario, Canada
| | - Kimberly Liu
- Mount Sinai Fertility, Toronto, Ontario, Canada
- Reprint requests: Kimberly Liu, M.D., M.S.L., Division of Reproductive Endocrinology and Infertility, Mount Sinai Fertility, University of Toronto, 250 Dundas Street West, Suite 700, Ontario, Canada.
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17
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Moravek MB, Dixon M, Pena SM, Obedin-Maliver J. Management of testosterone around ovarian stimulation in transmasculine patients: challenging common practices to meet patient needs-2 case reports. Hum Reprod 2023; 38:482-488. [PMID: 36644915 PMCID: PMC9977120 DOI: 10.1093/humrep/dead003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 12/05/2022] [Indexed: 01/17/2023] Open
Abstract
Approximately 50% of transmasculine people use testosterone for gender affirmation, yet very little is known about the effects of testosterone on future reproductive capacity. Moreover, there are no data to guide fertility specialists on how to manage testosterone leading up to or during ovarian stimulation. Most clinics require cessation of testosterone prior to ovarian stimulation in this setting of no data; however, the current literature does suggest a potential increase in dysphoria with cessation of testosterone and during stimulation. This divergence begs the question of whether clinicians may be doing more harm than good by enacting this requirement. Here, we present two cases of transmasculine individuals who were on testosterone prior to stimulation and maintained their testosterone dosage throughout stimulation as proof of concept, followed by a discussion of current clinical practice and providing some rationale to support continuation of testosterone throughout stimulation.
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Affiliation(s)
- Molly B Moravek
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Marjorie Dixon
- Anova Fertility and Reproductive Health, North York, Ontario, Canada
| | - Samantha M Pena
- Anova Fertility and Reproductive Health, North York, Ontario, Canada
| | - Juno Obedin-Maliver
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
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18
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Stolk THR, Asseler JD, Huirne JAF, van den Boogaard E, van Mello NM. Desire for children and fertility preservation in transgender and gender-diverse people: A systematic review. Best Pract Res Clin Obstet Gynaecol 2023; 87:102312. [PMID: 36806443 DOI: 10.1016/j.bpobgyn.2023.102312] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/30/2022] [Accepted: 01/13/2023] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- T H R Stolk
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, De Boelelaan 1117, Amsterdam University Medical Centers, the Netherlands; Amsterdam UMC, Department of Obstetrics & Gynaecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - J D Asseler
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, De Boelelaan 1117, Amsterdam University Medical Centers, the Netherlands; Amsterdam UMC, Department of Obstetrics & Gynaecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - J A F Huirne
- Amsterdam UMC, Department of Obstetrics & Gynaecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - E van den Boogaard
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, De Boelelaan 1117, Amsterdam University Medical Centers, the Netherlands; Amsterdam UMC, Department of Obstetrics & Gynaecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - N M van Mello
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, De Boelelaan 1117, Amsterdam University Medical Centers, the Netherlands; Amsterdam UMC, Department of Obstetrics & Gynaecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
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19
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Grateau S, Dupont C, Rivet-Danon D, Béranger A, Johnson N, Mathieu d'Argent E, Chabbert-Buffet N, Sermondade N. [Fertility preservation for transmen]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:797-804. [PMID: 36183988 DOI: 10.1016/j.gofs.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/23/2022] [Accepted: 09/20/2022] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- S Grateau
- Service de biologie de la reproduction - CECOS, Sorbonne université, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - C Dupont
- Service de biologie de la reproduction - CECOS, Sorbonne université, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - D Rivet-Danon
- Service de biologie de la reproduction - CECOS, Sorbonne université, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - A Béranger
- Service de biologie de la reproduction - CECOS, Sorbonne université, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - N Johnson
- Service de gynécologie-obstétrique-médecine de la reproduction, Sorbonne université, hôpital Tenon, AP-HP, Paris, France
| | - E Mathieu d'Argent
- Service de gynécologie-obstétrique-médecine de la reproduction, Sorbonne université, hôpital Tenon, AP-HP, Paris, France
| | - N Chabbert-Buffet
- Service de gynécologie-obstétrique-médecine de la reproduction, Sorbonne université, hôpital Tenon, AP-HP, Paris, France
| | - N Sermondade
- Service de biologie de la reproduction - CECOS, Sorbonne université, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France.
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Fertility Preservation and Reproductive Potential in Transgender and Gender Fluid Population. Biomedicines 2022; 10:biomedicines10092279. [PMID: 36140377 PMCID: PMC9496568 DOI: 10.3390/biomedicines10092279] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/09/2022] [Accepted: 09/11/2022] [Indexed: 11/16/2022] Open
Abstract
The gender diverse and transgender community is a minor patient group that is encountered with increasing frequency in the clinical setting, attributed to the improved awareness and access to medical facilities. Partial impairment to permanent elimination of fertility potential and outcomes depending on the treatment modality usually is a result of gender-affirming therapy, which includes both hormone therapy and surgical intervention. Although seldom conducted in the clinical field, transgender patients should be counseled on their fertility preservation options prior to medical and surgical gender transition. There is relatively limited data and clinical information regarding fertility preservation for transgender individuals. Current treatment regimens are based on protocols from fertility preservation after oncological treatments. Major barriers for the transgender population exist due to the lack of information provided and clinical narrative that is not familiar to the physician or health care provider, although there are various options for fertility preservation. A deeper understanding of this clinical agenda and the mandatory processes will ultimately result in a much more comprehensive and specific care for transgender individuals who are in great need for fertility counseling or treatment options that concern fertility preservation. In this review, current clinical approaches will be summarized and fertility preservation options along with ongoing and future clinical trials in fertility preservation for transgender individuals will be thoroughly reviewed.
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21
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Fertility Preservation for Transgender Males. Obstet Gynecol 2022; 139:1012-1017. [DOI: 10.1097/aog.0000000000004751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/03/2022] [Indexed: 10/18/2022]
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22
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Israeli T, Preisler L, Kalma Y, Samara N, Levi S, Groutz A, Azem F, Amir H. Similar fertilization rates and preimplantation embryo development among testosterone-treated transgender men and cisgender women. Reprod Biomed Online 2022; 45:448-456. [DOI: 10.1016/j.rbmo.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/13/2022] [Accepted: 04/26/2022] [Indexed: 11/25/2022]
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23
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Borrás A, Manau D, Fabregues F, Peralta S, Calafell JM, Casals G, Saco A, Agustí I, Carmona F. 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. J Assist Reprod Genet 2022; 39:527-541. [PMID: 35098405 PMCID: PMC8956766 DOI: 10.1007/s10815-021-02386-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 12/20/2021] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- Aina Borrás
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain
| | - Dolors Manau
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain ,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francesc Fabregues
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain ,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Sara Peralta
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain
| | - Josep Maria Calafell
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain
| | - Gemma Casals
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain ,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Adela Saco
- Department of Pathology, Hospital Clinic, University of Barcelona, Barcelona, Spain ,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Inés Agustí
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain
| | - Francisco Carmona
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona, Carrer de Villarroel N° 170, 08036 Barcelona, Spain ,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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O’Connell MA, Nguyen TP, Ahler A, Skinner SR, Pang KC. Approach to the Patient: Pharmacological Management of Trans and Gender-Diverse Adolescents. J Clin Endocrinol Metab 2022; 107:241-257. [PMID: 34476487 PMCID: PMC8684462 DOI: 10.1210/clinem/dgab634] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Indexed: 11/24/2022]
Abstract
Internationally, increasing numbers of children and adolescents with gender dysphoria are presenting for care. In response, gender-affirming therapeutic interventions that seek to align bodily characteristics with an individual's gender identity are more commonly being used. Depending on a young person's circumstances and goals, hormonal interventions may aim to achieve full pubertal suppression, modulation of endogenous pubertal sex hormone effects, and/or development of secondary sex characteristics congruent with their affirmed gender. This is a relatively novel therapeutic area and, although short-term outcomes are encouraging, longer term data from prospective longitudinal adolescent cohorts are still lacking, which may create clinical and ethical decision-making challenges. Here, we review current treatment options, reported outcomes, and clinical challenges in the pharmacological management of trans and gender-diverse adolescents.
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Affiliation(s)
- Michele A O’Connell
- Department of Endocrinology and Diabetes, The Royal Children’s Hospital Melbourne, Parkville, VIC 3052, Australia
- Department of Adolescent Medicine, The Royal Children’s Hospital Melbourne, Parkville, VIC 3052, Australia
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3010, Australia
| | - Thomas P Nguyen
- School of Medicine, Western Sydney University, Sydney, NSW 2560, Australia
| | - Astrid Ahler
- Reproductive Medicine and Gynecological Endocrinology (RME), University Hospital Basel, Basel, Switzerland
| | - S Rachel Skinner
- Speciality of Child and Adolescent Health, Faculty of Medicine and Health, Sydney University, Children’s Hospital Westmead, NSW 2145, Australia
| | - Ken C Pang
- Department of Adolescent Medicine, The Royal Children’s Hospital Melbourne, Parkville, VIC 3052, Australia
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3010, Australia
- Walter and Eliza Hall Institute for Medical Research, Parkville, VIC 3052, Australia
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Alur-Gupta S, Vu M, Vitek W. Adolescent Fertility Preservation: Where Do We Stand Now. Semin Reprod Med 2021; 40:69-78. [PMID: 34687030 DOI: 10.1055/s-0041-1735891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Adolescence is a period of flux for many body systems. While fertility potential typically increases after menarche, there are diseases where the opposite occurs and fertility preservation options need to be considered early. In cases of cancer, options vary by pubertal status and can include ovarian tissue cryopreservation, oocyte cryopreservation, sperm cryopreservation, and testicular tissue cryopreservation. Much remains to be learned about fertility and preservation options in those with differences in sexual development (DSDs); however, depending on the form of DSD, fertility preservation may not be necessary. Similarly, traditional fertility counseling in children with galactosemia may need to be changed, as data suggest that fertility rates attributed to other causes of premature ovarian insufficiency may not be as applicable to this disease. Adolescents with Turner's syndrome are at high risk for premature ovarian failure; therefore, it is important to consider options as early as possible since ovarian reserves are depleted quickly. On the other hand, transgender and gender diverse adolescents may even be able to undergo fertility preservation after starting hormone therapy. In all cases, there are additional ethical components including technical/surgical risks in childhood, offering experimental therapies without creating false hope and evaluating children's consent and assent capabilities that must be considered.
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Affiliation(s)
- Snigdha Alur-Gupta
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, New York
| | - Michelle Vu
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, New York
| | - Wendy Vitek
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, New York
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Gale J, Magee B, Forsyth-Greig A, Visram H, Jackson A. Oocyte cryopreservation in a transgender man on long-term testosterone therapy: a case report. F S Rep 2021; 2:249-251. [PMID: 34278362 PMCID: PMC8267393 DOI: 10.1016/j.xfre.2021.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/25/2021] [Accepted: 02/13/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To report a case of ovarian stimulation for the purposes of oocyte cryopreservation in a transgender man without cessation of long-term testosterone therapy. Design Report of a unique case of fertility preservation through ovarian stimulation and oocyte cryopreservation in a transgender man who had been on testosterone therapy for 18 months before treatment. The patient elected to continue testosterone therapy throughout ovarian stimulation and oocyte retrieval. To our knowledge, there have not been any published reports of patients undergoing oocyte cryopreservation while continuing long-term testosterone therapy. Setting Private fertility clinic with university affiliation. Patients A 20-year-old transgender man undergoing oocyte cryopreservation before gonadectomy. Interventions Fertility preservation through oocyte cryopreservation. Main Outcome Measures This patient had a robust response to ovarian gonadotropin stimulation. Leuprolide acetate was used for final oocyte maturation to minimize ovarian hyperstimulation syndrome risk. Results Cryopreservation of 22 mature oocytes. Conclusions Cryopreservation of mature oocytes is possible for patients on continued long-term testosterone therapy. The impact of long-term testosterone therapy on markers of ovarian reserve, reproductive potential, and long-term reproductive outcomes have yet to be elucidated and further studies are needed in this area.
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Affiliation(s)
- Jenna Gale
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Fertility Centre, Ottawa, Ontario, Canada
| | - Bryden Magee
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Fertility Centre, Ottawa, Ontario, Canada.,Centre for Excellence in Transgender Medicine, West Ottawa Specialty Care, Ottawa, Ontario, Canada
| | - Amanda Forsyth-Greig
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Hasina Visram
- Department of Obstetrics and Gynecology, Queens University, Kingston, Ontario, Canada
| | - Aaron Jackson
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Fertility Centre, Ottawa, Ontario, Canada
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Endocrinological and ovarian histological investigations in assigned female at birth transgender people undergoing testosterone therapy. Reprod Biomed Online 2021; 43:289-297. [PMID: 34244072 DOI: 10.1016/j.rbmo.2021.05.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/04/2021] [Accepted: 05/09/2021] [Indexed: 01/10/2023]
Abstract
RESEARCH QUESTION What are the hormonal and ovarian histological effects of a gender affirming hormonal therapy in assigned female at birth (AFAB) transgender people? DESIGN Prospective observational study of 70 AFAB transgender people taking testosterone therapy before gender-affirming surgery (hystero-oophorectomy). A gynaecological ultrasonographic scan was undertaken and serum hormone concentrations measured, including anti-Müllerian hormone (AMH) and androgenic profile. Histological ovarian evaluation was assessed in both ovaries, including the developmental stages of the follicles. RESULTS The mean age of the population was 27.7+/-5.14 years. The main biochemical parameters were total testosterone levels 781.5 ± 325.9 ng/dl; AMH levels 3.2 ± 1.4 ng/ml; FSH and LH levels 4.9 ± 2.5 IU/l and 3.9 ± 2.9 IU/l, respectively; and oestradiol values 47.6 ± 13.7 pg/ml. Fifty-five AFAB underwent gynaecological ultrasound before surgery and antral follicles were found in 43 out of 47 ultrasounds (91.5%) (without the presence of a dominant follicle or corpus luteum). Histological follicles were mostly in the primordial stage (88.0) and 3.3% were atretic. The thickness of the tunica albuginea was widely heterogeneous (range 0.15-1.45 mm) and luteinization of the stromal cells was observed in 68.6% of the samples. A negative correlation between testosterone levels and total antral follicles was found (Rs= -0.306, P = 0.029). CONCLUSIONS AFAB transgender people taking testosterone therapy show cortical follicle distribution in the range previously reported in fertile cisgender women of reproductive age. The follicular population may not be altered as a result of the gender-affirming hormonal therapy, although some cortical and stromal changes have been observed.
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