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Falck FAOK, Dhejne CMU, Frisén LMM, Armuand GM. Subjective Experiences of Pregnancy, Delivery, and Nursing in Transgender Men and Non-Binary Individuals: A Qualitative Analysis of Gender and Mental Health Concerns. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:1981-2002. [PMID: 38228983 PMCID: PMC11106200 DOI: 10.1007/s10508-023-02787-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 01/18/2024]
Abstract
Studies of how gender-diverse individuals experience pregnancy, childbirth, and nursing remain few, mainly focus on the US and contain scarce information about mental health concerns peri-partum. This hinders informed reproductive health decisions and counseling. We used in-depth interviews to examine how gestational gender-diverse individuals in Sweden experience the process of planning and undergoing pregnancy, delivery, and nursing. In total, 12 participants, identifying on the masculine side of the gender spectrum or as non-binary, who had attended Swedish antenatal care and delivered a live birth, were included in the study. Data were analyzed using qualitative thematic content analysis. The analysis resulted in one overarching theme: sustaining gender congruence during pregnancy and three main categories: (1) considering pregnancy; (2) undergoing pregnancy and childbirth; and (3) postnatal reflections. The association between childbearing and being regarded as female permeated narratives. Participants renegotiated the feminine connotations of pregnancy, accessed gender-affirming treatment, and concealed their pregnancy to safeguard their gender congruence. Mis-gendering and breast enlargement triggered gender dysphoria. Social judgment, loneliness, information shortages, hormonal influence and cessation of testosterone increased gender dysphoria and strained their mental health. Depression exacerbated gender dysphoria and made it harder to claim one's gender identity. Dissociation was used to handle a feminized body, vaginal delivery, and nursing. Pregnancy was easier to envision and handle after masculinizing gender-affirming treatments. The results deepen the understanding of gender dysphoria and may be used to inform reproductive counseling and healthcare development. Research outcomes on mental health concerns provide a basis for further research.
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Affiliation(s)
- Felicitas A O K Falck
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- ANOVA, Karolinska University Hospital, 171 76, Stockholm, Sweden.
- Psychiatry Southwest, Karolinska University Hospital in Huddinge, Stockholm, Sweden.
| | - Cecilia M U Dhejne
- ANOVA, Karolinska University Hospital, 171 76, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Louise M M Frisén
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Gabriela M Armuand
- School of Health and Welfare, Faculty of Health Sciences 1, Dalarna University, Falun, Sweden
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2
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White J, Jackson A, Druce I, Gale J. Oocyte cryopreservation and reciprocal in vitro fertilization in a transgender man on long term testosterone gender-affirming hormone therapy: a case report. F S Rep 2024; 5:111-113. [PMID: 38524208 PMCID: PMC10958692 DOI: 10.1016/j.xfre.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/21/2023] [Accepted: 11/06/2023] [Indexed: 03/26/2024] Open
Abstract
Objective To report a successful case of oocyte cryopreservation and subsequent in vitro fertilization (IVF) in a transgender male receiving continued testosterone gender-affirming hormone therapy, followed by reciprocal embryo transfer (ET). Design A case report of a rare case of fertility preservation in a transgender man with concomitant use of testosterone therapy for 4 years before and during ovarian stimulation. Setting Private fertility clinic with university affiliation. Patients A 26-year-old transgender man undergoing oocyte cryopreservation before gender-affirming surgery. Interventions Fertility preservation using oocyte cryopreservation and IVF with reciprocal fresh ET into a cisfemale partner. Main Outcome Measures Successful oocyte cryopreservation, oocyte thawing, and reciprocal IVF cycle. Results Oocyte cryopreservation of 29 mature oocytes. Sixteen mature oocytes survived the thaw, and 12 were fertilized with intracytoplasmic sperm injection. A fresh ET of an advanced blastocyst resulted in a clinical pregnancy and live birth. Conclusions Fertility preservation with oocyte cryopreservation or IVF with embryo cryopreservation is feasible for patients on continued long-term testosterone gender-affirming therapy. Future studies on egg quality and reproductive outcomes are required. Our case report demonstrates a promising outcome in this patient population.
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Affiliation(s)
- Justin White
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Fertilty Centre, Ottawa, Ontario, Canada
| | - Aaron Jackson
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Fertilty Centre, Ottawa, Ontario, Canada
| | - Irena Druce
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jenna Gale
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Fertilty Centre, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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3
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Raja NS, Rubin ES, Moravek MB. A Review of Animal Models Investigating the Reproductive Effects of Gender-Affirming Hormone Therapy. J Clin Med 2024; 13:1183. [PMID: 38398495 PMCID: PMC10889210 DOI: 10.3390/jcm13041183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/08/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
Gender-affirming hormone therapy (GAHT) is an important component in the process of transitioning for many transgender and gender-diverse (TGD) individuals. Multiple medical organizations recommend fertility preservation counseling prior to initiation of GAHT; however, there remains little high-quality data regarding the impact of GAHT on fertility and reproductive function. A PubMed literature review was performed using Boolean search operators linking keywords or phrases such as "mouse", "rat", "primate", "animal model", "transgender", "gender", "estrogen", "testosterone", "fertility", and "fertility preservation". Recent research has produced a number of animal models of GAHT that utilize similar hormonal regimens and produce similar phenotypic results to those used and observed in human patients. Specific to testosterone(T)-containing GAHT, animals demonstrate loss of menstrual cyclicity with therapy, resumption of menses on cessation of therapy, suppression of gonadotropin levels, and physical changes such as clitoromegaly. Models mimicking GAHT for transmasculine individuals in the peripubertal period demonstrate that pretreatment with GnRHa therapy does not modify the effects of subsequent T administration, which were similar to those described in adult models. Both models suggest promising potential for future fertility with cessation of T. With estradiol (E)-containing GAHT, animals exhibit decreased size of testicles, epididymis, and seminal vesicles, as well as ongoing production of spermatocytes, and seminiferous tubule vacuolization. Given the ethical challenges of conducting human studies in this area, high-fidelity animal models represent a promising opportunity for investigation and could eventually transform clinical counseling about the necessity of fertility preservation. Future studies should better delineate the interactions (if any exist) between treatment attributes such as dosing and duration with the extent of reversibility of reproductive perturbations. The development of models of peripubertal feminizing GAHT is an additional area for future work.
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Affiliation(s)
- Nicholas S. Raja
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Elizabeth S. Rubin
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR 97239, USA;
| | - Molly B. 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
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4
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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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5
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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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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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8
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D'Amato A, Cascardi E, Etrusco A, Laganà AS, Schonauer LM, Cazzato G, Vimercati A, Malvasi A, Damiani GR, Di Naro E, Trojano G, Cicinelli E, Vitagliano A, Dellino M. "Lights and Shades" of Fertility Preservation in Transgender Men Patients: A Clinical and Pathological Review. Life (Basel) 2023; 13:1312. [PMID: 37374095 DOI: 10.3390/life13061312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/25/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
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.
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Affiliation(s)
- Antonio D'Amato
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Eliano Cascardi
- Department of Medical Sciences, University of Turin, 10124 Turin, Italy
- Pathology Unit, FPO-IRCCS Candiolo Cancer Institute, 10060 Candiolo, Italy
| | - Andrea Etrusco
- Unit of Gynecologic Oncology, ARNAS "Civico-Di Cristina-Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS "Civico-Di Cristina-Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Luca Maria Schonauer
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Gerardo Cazzato
- Department of Emergency and Organ Transplantation, Pathology Section, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Antonella Vimercati
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Antonio Malvasi
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Gianluca Raffaello Damiani
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Edoardo Di Naro
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Giuseppe Trojano
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Ettore Cicinelli
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Amerigo Vitagliano
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Miriam Dellino
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
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9
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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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10
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Walters KA, Moreno-Asso A, Stepto NK, Pankhurst MW, Rodriguez Paris V, Rodgers RJ. Key signalling pathways underlying the aetiology of polycystic ovary syndrome. J Endocrinol 2022; 255:R1-R26. [PMID: 35980384 DOI: 10.1530/joe-22-0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/11/2022] [Indexed: 11/08/2022]
Abstract
Polycystic ovary syndrome (PCOS) is a common endocrine condition characterised by a range of reproductive, endocrine, metabolic and psychological abnormalities. Reports estimate that around 10% of women of reproductive age are affected by PCOS, representing a significant prevalence worldwide, which poses a high economic health burden. As the origin of PCOS remains largely unknown, there is neither a cure nor mechanism-based treatments leaving patient management suboptimal and focused solely on symptomatic treatment. However, if the underlying mechanisms underpinning the development of PCOS were uncovered then this would pave the way for the development of new interventions for PCOS. Recently, there have been significant advances in our understanding of the underlying pathways likely involved in PCOS pathogenesis. Key insights include the potential involvement of androgens, insulin, anti-Müllerian hormone and transforming growth factor beta in the development of PCOS. This review will summarise the significant scientific discoveries on these factors that have enhanced our knowledge of the mechanisms involved in the development of PCOS and discuss the impact these insights may have in shaping the future development of effective strategies for women with PCOS.
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Affiliation(s)
- Kirsty A Walters
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Alba Moreno-Asso
- Institute for Health and Sport, Victoria University, Footscray, Victoria, Australia
- Australian Institute of Musculoskeletal Science, Victoria University, St. Albans, Victoria, Australia
| | - Nigel K Stepto
- Institute for Health and Sport, Victoria University, Footscray, Victoria, Australia
- Australian Institute of Musculoskeletal Science, Victoria University, St. Albans, Victoria, Australia
- Monash Centre for Health Research and Implementation, Monash University and Monash Health, Clayton, Victoria, Australia
- Medicine at Western Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael W Pankhurst
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Valentina Rodriguez Paris
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Raymond J Rodgers
- The Robinson Research Institute, School of Biomedicine, The University of Adelaide, Adelaide, South Australia, Australia
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AOP key event relationship report: Linking decreased androgen receptor activation with decreased granulosa cell proliferation of gonadotropin-independent follicles. Reprod Toxicol 2022; 112:136-147. [PMID: 35868514 DOI: 10.1016/j.reprotox.2022.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/14/2022] [Accepted: 07/16/2022] [Indexed: 02/08/2023]
Abstract
We recently proposed to formally recognize Key Event Relationships (KERs) as building blocks of Adverse Outcome Pathways (AOPs) that can be independently developed and peer-reviewed. Here, we follow this approach and provide an independent KER from AOP345, which describes androgen receptor (AR) antagonism leading to decreased female fertility. This KER connects AR antagonism to reduced granulosa cell proliferation of gonadotropin-independent follicles (KER2273). We have developed both the KER and the two adjacent Key Events (KEs). A systematic approach was used to ensure that all relevant supporting evidence for KER2273 was retrieved. Supporting evidence for the KER highlights the importance of AR action during the early stages of follicular development. Both biological plausibility and empirical evidence are presented, with the latter also assessed for quality. We believe that tackling isolated KERs instead of whole AOPs will accelerate the AOP development. Faster AOP development will lead to the development of simple test methods that will aid screening of chemicals, endocrine disruptor identification, risk assessment, and subsequent regulation.
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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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Neves AR, Montoya-Botero P, Polyzos NP. Androgens and diminished ovarian reserve: the long road from basic science to clinical implementation. A comprehensive and systematic review with meta-analysis. Am J Obstet Gynecol 2022; 227:401-413.e18. [PMID: 35364061 DOI: 10.1016/j.ajog.2022.03.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 03/16/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed to present a narrative review regarding androgen production, androgens' role in folliculogenesis, and the available therapeutic approaches for androgen supplementation, and to perform a systematic review and meta-analysis regarding the impact of androgens (dehydroepiandrosterone/testosterone) compared with placebo or no treatment on ovarian response and pregnancy outcomes in patients with diminished ovarian reserve and/or poor ovarian responders. DATA SOURCES An electronic search of MEDLINE, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials, Scopus, ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry, was conducted for studies published until September 2021. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared ovarian response and/or pregnancy outcomes between the different in vitro fertilization protocols using androgens (ie, dehydroepiandrosterone and testosterone) and conventional in vitro fertilization stimulation in patients with diminished ovarian reserve and/or poor ovarian responders were included. METHODS The quality of each study was evaluated with the revised Cochrane risk-of-bias tool for randomized trials (RoB 2). The meta-analysis used random-effects models. All results were interpreted on the basis of intention-to-treat analysis (defined as the inclusion of all randomized patients in the denominator). Risk ratios and 95% confidence intervals were used and combined for meta-analysis. RESULTS No significant differences were found regarding the number of oocytes retrieved (mean difference, 0.76; 95% confidence interval, -0.35 to 1.88), mature oocytes retrieved (mean difference, 0.25; 95% confidence interval, -0.27 to 0.76), clinical pregnancy rate (risk ratio, 1.17; 95% confidence interval, 0.87-1.57), live-birth rate (risk ratio, 0.97; 95% confidence interval, 0.47-2.01), or miscarriage rate (risk ratio, 0.80; 95% confidence interval, 0.29-2.22) when dehydroepiandrosterone priming was compared with placebo or no treatment. Testosterone pretreatment yielded a higher number of oocytes retrieved (mean difference, 0.94; 95% confidence interval, 0.46-1.42), a higher clinical pregnancy rate (risk ratio, 2.07; 95% confidence interval, 1.33-3.20), and higher live-birth rate (risk ratio, 2.09; 95% confidence interval, 1.11-3.95). CONCLUSION Although dehydroepiandrosterone did not present a clear effect on outcomes of assisted reproductive techniques, we found a potentially beneficial effect of testosterone priming on ovarian response and pregnancy outcomes. However, results should be interpreted with caution, taking into account the low to moderate quality of the available evidence.
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Affiliation(s)
- Ana Raquel Neves
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain; Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
| | - Pedro Montoya-Botero
- Conceptum - Unidad de Fertilidad del Country, Bogotá, Colombia; Department of Epidemiology and Biostatistics, Fundación Universitaria de Ciencias de la Salud - FUCS, Bogotá, Colombia
| | - Nikolaos P Polyzos
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain; Faculty of Medicine and Health Sciences, Ghent University (UZ Gent), Ghent, Belgium.
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14
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Yaish I, Tordjman K, Amir H, Malinger G, Salemnick Y, Shefer G, Serebro M, Azem F, Golani N, Sofer Y, Stern N, Greenman Y. Functional ovarian reserve in transgender men receiving testosterone therapy: evidence for preserved anti-Müllerian hormone and antral follicle count under prolonged treatment. Hum Reprod 2021; 36:2753-2760. [PMID: 34411251 DOI: 10.1093/humrep/deab169] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/19/2021] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Is the functional ovarian reserve in transgender men affected by testosterone therapy? SUMMARY ANSWER Serum anti-Müllerian Hormone (AMH) levels slightly decrease during testosterone treatment but remain within the normal range, suggesting preserved follicular ovarian reserve. WHAT IS KNOWN ALREADY Few small studies have investigated the impact of gender-affirming treatment on reproduction in transgender men. Conflicting results were reached concerning ovarian morphology and AMH levels in this context. STUDY DESIGN, SIZE, DURATION The study consisted of two arms. The first arm was a prospective pilot study, which enrolled 56 transgender men (median age 22.5 [interquartile range (IQR)-19-27.7] years), 27 of whom had polycystic ovary syndrome (PCOS), prior to the initiation of gender-affirming testosterone therapy. A structured assessment was conducted prior to, and at 3 and 12 months after treatment initiation. The second arm was a cross-sectional study that comprised 47 transgender men (median age 24 [IQR-20-31] years) who received testosterone for a median duration of 35 [IQR 13-62] months. The main outcome measures were serum AMH and antral follicle count (AFC) as indices of ovarian follicular reserve. PARTICIPANTS/MATERIALS, SETTING, METHODS The study was conducted at a tertiary center for transgender health. Gender-affirming therapy was administered according to standard practice. AFC was determined by pelvic (abdominal or transvaginal) ultrasound and blood collection for measurements of AMH, testosterone, estradiol, LH and FSH was performed at the designated time-points. MAIN RESULTS AND THE ROLE OF CHANCE Prospective arm for the entire group we observed a decrease of 0.71 ng/ml in AMH levels between baseline and 12 months (P = 0.01). When expressed in age-specific percentiles, AMH went from the 47.37th to the 40.25th percentile at 12 months (P < 0.001). In a sub-group analysis, a decline of 9.52 points in age-specific percentile was seen in subjects with PCOS (P < 0.001), while no changes were detected in the non-PCOS group. Testosterone treatment did not affect AFC over time in the entire cohort. In the sub-group analysis, a mean decrease of 5.0 follicles was detected between baseline and the 12 months assessment (P = 0.047) only in subjects with PCOS. In the cross-sectional study, AMH inversely correlated with age but not with treatment duration. Notably AMH did not deviate from the 50th age-specific percentile. Finally, four men fathered biological children after being under testosterone treatment for up to 12 years. LIMITATIONS, REASONS FOR CAUTION The limited sample size of the pilot study should be kept in mind. An additional limitation is the lack of a control group in the prospective study, as each participant served as his own control. Also, roughly 40% of the ultrasound examinations were performed transabdominally, potentially affecting the accuracy of the AFC measurements.As study participants were quite young, our reassuring data may not apply to older transgender men, either because of an age-related decline in ovarian reserve or to possible long-term effects of testosterone therapy. Furthermore, the chances for fertility preservation may be more limited in subjects with PCOS. WIDER IMPLICATIONS OF THE FINDINGS This is an additional contribution to the emerging evidence that prolonged testosterone treatment may not be a major obstacle to later fertility potential in transgender men desirous of having children. Larger confirmatory studies, and particularly more with reproductive outcome data, are needed for evidence-based fertility counseling prior to treatment initiation in these subjects. STUDY FUNDING/COMPETING INTEREST(S) This study received no funding. The authors have no competing interests to declare. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- I Yaish
- Institute of Endocrinology, Diabetes, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - K Tordjman
- Institute of Endocrinology, Diabetes, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H Amir
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Lis Maternity Hospital, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - G Malinger
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Lis Maternity Hospital, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Y Salemnick
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Lis Maternity Hospital, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - G Shefer
- Institute of Endocrinology, Diabetes, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Serebro
- Institute of Endocrinology, Diabetes, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - F Azem
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Lis Maternity Hospital, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - N Golani
- Institute of Endocrinology, Diabetes, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Y Sofer
- Institute of Endocrinology, Diabetes, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - N Stern
- Institute of Endocrinology, Diabetes, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Greenman
- Institute of Endocrinology, Diabetes, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Schwartz AR, Moravek MB. Reproductive potential and fertility preservation in transgender and nonbinary individuals. Curr Opin Obstet Gynecol 2021; 33:327-334. [PMID: 34173770 DOI: 10.1097/gco.0000000000000729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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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, Michigan, USA
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16
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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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17
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Schneider F, Dabel J, Sandhowe-Klaverkamp R, Neuhaus N, Schlatt S, Kliesch S, Wistuba J. Serum and intratesticular inhibin B, AMH, and spermatogonial numbers in trans women at gender-confirming surgery: An observational study. Andrology 2021; 9:1781-1789. [PMID: 34085780 DOI: 10.1111/andr.13059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/30/2021] [Accepted: 05/23/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Anti-Müllerian hormone and inhibin B are produced by Sertoli cells. Anti-Müllerian hormone secretion indicates an immature Sertoli cell state. Inhibin B serves as a marker of male fertility. Identification of markers reflecting the presence of germ cells is of particular relevance in trans persons undergoing gender-affirming hormone therapy in order to offer individualized fertility preservation methods. OBJECTIVES Serum and intratesticular inhibin B and anti-Müllerian hormone values were assessed and related to clinical features, laboratory values, and germ cell numbers. MATERIALS AND METHODS Twenty-two trans women from three clinics were included. As gender-affirming hormone therapy, 10-12.5 mg of cyproterone acetate plus estrogens were administered. Height, weight, age, medication, and treatment duration were inquired by questionnaires. Serum luteinizing hormone, follicle-stimulating hormone, testosterone, and estradiol were measured by immuno-assays. Serum and intratesticular inhibin B and anti-Müllerian hormone were measured by commercially available ELISAs. Spermatogonia were quantified as spermatogonia per cubic millimeter testicular tissue applying a morphometric analysis of two independent testicular cross-sections per individual after MAGEA4 immunostaining. RESULTS Patients with high inhibin B levels presented with a higher number of spermatogonia (*p < 0.05). Furthermore, mean serum inhibin B was associated with low age (*p < 0.05), low follicle-stimulating hormone (*p < 0.05), and low testosterone (*p < 0.05). Serum anti-Müllerian hormone, however, was not related to spermatogonial numbers. It correlated with high testosterone (*p < 0.05) and high follicle-stimulating hormone (*p < 0.05) only. High intratesticular inhibin B was accompanied by high luteinizing hormone (*p < 0.05), high follicle-stimulating hormone (**p < 0.01), and high testosterone levels (**p < 0.01). Higher the intratesticular anti-Müllerian hormone levels, the longer gender-affirming hormone therapy was administered (*p < 0.05). DISCUSSION AND CONCLUSION Serum inhibin B levels indicate the presence of spermatogonia, whereas anti-Müllerian hormone seems not to be a reliable marker concerning germ cell abundance.
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Affiliation(s)
- Florian Schneider
- Institute of Reproductive and Regenerative Medicine, Centre of Reproductive Medicine and Andrology, University Hospital Muenster, Muenster, Germany.,Department of Clinical and Surgical Andrology, Centre of Reproductive Medicine and Andrology, University Hospital Muenster, Muenster, Germany
| | - Jennifer Dabel
- Institute of Reproductive and Regenerative Medicine, Centre of Reproductive Medicine and Andrology, University Hospital Muenster, Muenster, Germany
| | - Reinhild Sandhowe-Klaverkamp
- Institute of Reproductive and Regenerative Medicine, Centre of Reproductive Medicine and Andrology, University Hospital Muenster, Muenster, Germany
| | - Nina Neuhaus
- Institute of Reproductive and Regenerative Medicine, Centre of Reproductive Medicine and Andrology, University Hospital Muenster, Muenster, Germany
| | - Stefan Schlatt
- Institute of Reproductive and Regenerative Medicine, Centre of Reproductive Medicine and Andrology, University Hospital Muenster, Muenster, Germany
| | - Sabine Kliesch
- Department of Clinical and Surgical Andrology, Centre of Reproductive Medicine and Andrology, University Hospital Muenster, Muenster, Germany
| | - Joachim Wistuba
- Institute of Reproductive and Regenerative Medicine, Centre of Reproductive Medicine and Andrology, University Hospital Muenster, Muenster, Germany
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18
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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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19
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Lierman S, Tolpe A, De Croo I, De Gheselle S, Defreyne J, Baetens M, Dheedene A, Colman R, Menten B, T'Sjoen G, De Sutter P, Tilleman K. 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. Fertil Steril 2021; 116:1068-1076. [PMID: 33832736 DOI: 10.1016/j.fertnstert.2021.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/05/2021] [Accepted: 03/05/2021] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Sylvie Lierman
- Department for Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
| | - Annelies Tolpe
- Department for Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
| | - Ilse De Croo
- Department for Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Justine Defreyne
- Department of Endocrinology - Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Machteld Baetens
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Annelies Dheedene
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Roos Colman
- Biostatistics Unit, Ghent University Hospital, Ghent, Belgium
| | - Björn Menten
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Guy T'Sjoen
- Department of Endocrinology - Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Petra De Sutter
- Department for Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
| | - Kelly Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Ghent, Belgium.
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20
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Yan M, Bustos SS, Kuruoglu D, Ciudad P, Forte AJ, Kim EA, Del Corral G, Manrique OJ. Systematic review of fertility preservation options in transgender patients: a guide for plastic surgeons. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:613. [PMID: 33987311 DOI: 10.21037/atm-20-4523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Maria Yan
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Doga Kuruoglu
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Antonio J Forte
- Division of Plastic and Reconstructive Surgery, Mayo Clinic Florida Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Esther A Kim
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, California, USA
| | - Gabriel Del Corral
- Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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21
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Building a Multidisciplinary Academic Surgical Gender-affirmation Program: Lessons Learned. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3478. [PMID: 33968551 PMCID: PMC8099415 DOI: 10.1097/gox.0000000000003478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 01/25/2021] [Indexed: 11/26/2022]
Abstract
Background: Every day, we see more patients present to hospitals and clinics seeking gender-affirmation care to ameliorate the symptoms of gender dysphoria. However, to provide a multidisciplinary approach, it is important to offer an integrated clinical program that provides mental health assessment, endocrine therapy, physical therapy, research, and the full spectrum of surgical services devoted to transgender patients. This article describes our experience on building a specialized, multidisciplinary, academic state-of-the-art gender-affirmation program. Methods: Herein, we describe the main and critical components on how to build a multidisciplinary academic gender-affirmation program. We share our lessons learned from this experience and describe how to overcome some of the obstacles during the process. Results: Building a multidisciplinary academic gender-affirmation program requires an invested team, as each and every member is essential for feedback, referrals, and to improve patient’s experience. Institutional support is essential and by far the most important component to overcome some of the obstacles during the process. Having all team members working under the same institution provides all the critical components needed to improve outcomes and patient satisfaction. In addition, the collection of prospective data with a well-structured research team will provide information needed to improve clinical services and standardize clinical protocols, while leaving space for innovation. Conclusions: This article describes the steps and experience needed to build a multidisciplinary holistic academic gender-affirmation program. We provide our lessons learned during the process that will help guide those who intend to start an academic gender-affirmation program.
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22
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Serum testosterone levels are positively associated with serum anti-mullerian hormone levels in infertile women. Sci Rep 2021; 11:6336. [PMID: 33737663 PMCID: PMC7973568 DOI: 10.1038/s41598-021-85915-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/05/2021] [Indexed: 11/09/2022] Open
Abstract
Anti-Mullerian hormone (AMH) and testosterone (T) both play distinct roles in the early stages of folliculogenesis. However, the relationship between serum T and AMH levels is poorly understood. This study aimed to investigate the association between serum T and AMH levels in infertile women. A total of 1935 infertile women aged 20-46 years were included in the cross-sectional study and divided into four quartile groups (Q1 to Q4) based on serum T levels. Compared to the subjects in the highest T quartile (Q4), those in the lowest T quartile (Q1) showed significantly lower AMH levels. After adjustment for age, body weight, body mass index and FSH, increasing T quartile categories were associated with higher AMH levels. Binary logistic regression analyses revealed that the odds for the risk of diminished ovarian reserve (DOR) were 11.44-fold higher in Q1 than in Q4 and the odds for the risk of excess ovarian reserve (EOR) were 10.41-fold higher in Q4 than in Q1. Our data show that serum T levels are positively associated with serum AMH levels and suggest that androgen insufficiency may be a potential risk factor for DOR; androgen excess may lead to EOR in infertile women.
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Contraception across transgender. Int J Impot Res 2021; 33:710-719. [PMID: 33558672 DOI: 10.1038/s41443-021-00412-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 11/09/2022]
Abstract
Sexual and reproductive issues are essential elements of well-being in cisgenders as well as for the transgender population. Gender-affirming hormonal treatments (GAHTs) aim to induce phenotypical changes congruent with the desired gender and subsequent reduction of gender dysphoria. While genital surgical procedures including hysterectomy and/or adenectomy cause permanent loss of ability to conceive, GAHT may induce a varying degree of reversible loss of fertility. For these reasons, transgender men and women need to be counseled concerning contraceptive options and potential effects of treatment on reproductive function before initiating GAHT. The literature reports that sexual activity with genital involvement is performed by less than half of transgender persons who have been sexually active with a partner in the past. Testosterone (T) is the most commonly used compound in transmen and usually leads to amenorrhea within 1-12 months from first administration, however cessation of menses does not mean anovulation. Some studies report cases of unintended pregnancies among transgender men under masculinizing therapy, therefore T treatment cannot be considered a contraceptive option. Currently available contraceptive options have pros and cons in transmen and scarce literature exists on their use. The effects of GAHT on fertility in transwomen are even less well known. Prolonged estrogen exposure induces sperm suppression and morphological changes of the spermatozoa, however the degree of resulting pregnancy protection is unclear. Further research to inform the contraceptive counseling in this population is mandatory.
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Bishop CV, Takahashi D, Mishler E, Slayden OD, Roberts CT, Hennebold J, True C. Individual and combined effects of 5-year exposure to hyperandrogenemia and Western-style diet on metabolism and reproduction in female rhesus macaques. Hum Reprod 2021; 36:444-454. [PMID: 33313720 PMCID: PMC7829549 DOI: 10.1093/humrep/deaa321] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/20/2020] [Indexed: 12/11/2022] Open
Abstract
STUDY QUESTION What is the impact of prolonged exposure to hyperandrogenemia (T), Western-style diet (WSD) and the combination on metabolic and reproductive function in female rhesus macaques, particularly in the post-partum period? SUMMARY ANSWER Combined T + WSD worsened measures of insulin sensitivity and parameters of cyclicity following prolonged (5 years) exposure, but there was no effect on post-partum metabolic function. WHAT IS KNOWN ALREADY Women with hyperandrogenemia due to polycystic ovary syndrome are at higher risk for gestational diabetes and Type 2 diabetes post-partum, but it is unknown if this is related to hyperandrogenemia. Hyperandrogenemia in the presence of a WSD worsens metabolic function in female nonhuman primates. STUDY DESIGN, SIZE, DURATION Female rhesus macaques began treatment near menarche (roughly 2.5 years of age) consisting of either cholesterol (control; C) or testosterone (T) implants (average serum levels 1.4 ng/ml) and exposure to standard monkey chow or a WSD (15 vs 36% of calories from fat, respectively). The four groups were maintained on treatment for 3 years, underwent a fertility trial in Year 4 and continued with treatments through Year 5. PARTICIPANTS/MATERIALS, SETTING, METHODS Metabolic measurements (glucose tolerance tests and double X-ray absorptiometry scans) were performed yearly, and results from 5 years of treatment are reported for all animals. Animals were bled daily for 30 days at 5 years to capture changes in ovarian cycle hormones, and ultrasound measurements were performed during the early follicular and luteal phase. MAIN RESULTS AND THE ROLE OF CHANCE After 5 years of treatment, WSD exposure moderately increased body weight and body fat, although control animals also had a high body mass index due to ad libitum feeding. Animals in the T + WSD group had increased fasting insulin and insulin secretion during an intravenous glucose tolerance test. WSD exposure also altered ovarian cycles, delaying the time to the E2 surge, decreasing progesterone and anti-Müllerian hormone levels and increasing the number of antral follicles present by ultrasound. Longitudinal assessment of metabolic function for only those animals that became pregnant in Year 4 of treatment revealed no differences in post-partum metabolism between groups, although WSD resulted in overall elevated weights, body fat and measures of insulin resistance. LARGE SCALE DATA None. LIMITATIONS, REASONS FOR CAUTION The small sample size and heterogeneity in metabolic effects observed in the T + WSD group are limitations of the current study, with only a subset of animals in this group showing impaired insulin resistance relative to controls. In addition, obesity in the C group prevented comparisons to lean animals. WIDER IMPLICATIONS OF THE FINDINGS Hyperandrogenemia combined with WSD had a greater impact on insulin sensitivity and ovarian function than either treatment alone. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by NIH grant P50 HD071836 to C.T.R., J.H. and C.T. and P51 OD011092 for support of the Oregon National Primate Research Center. All authors declare no competing interests.
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Affiliation(s)
- Cecily V Bishop
- Division of Reproductive & Developmental Sciences, Oregon National Primate Research Center, Beaverton, OR, USA
- Department of Animal and Rangeland Sciences, College of Agricultural Sciences, Oregon State University, Corvallis, OR, USA
| | - Diana Takahashi
- Division of Cardiometabolic Health, Oregon National Primate Research Center, Beaverton, OR, USA
| | - Emily Mishler
- Division of Reproductive & Developmental Sciences, Oregon National Primate Research Center, Beaverton, OR, USA
| | - Ov D Slayden
- Division of Reproductive & Developmental Sciences, Oregon National Primate Research Center, Beaverton, OR, USA
| | - Charles T Roberts
- Division of Reproductive & Developmental Sciences, Oregon National Primate Research Center, Beaverton, OR, USA
- Division of Cardiometabolic Health, Oregon National Primate Research Center, Beaverton, OR, USA
| | - Jon Hennebold
- Division of Reproductive & Developmental Sciences, Oregon National Primate Research Center, Beaverton, OR, USA
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Cadence True
- Division of Reproductive & Developmental Sciences, Oregon National Primate Research Center, Beaverton, OR, USA
- Division of Cardiometabolic Health, Oregon National Primate Research Center, Beaverton, OR, USA
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Greene DN, Schmidt RL, Winston-McPherson G, Rongitsch J, Imborek KL, Dickerson JA, Drees JC, Humble RM, Nisly N, Dole NJ, Dane SK, Frerichs J, Krasowski MD. Reproductive Endocrinology Reference Intervals for Transgender Men on Stable Hormone Therapy. J Appl Lab Med 2020; 6:41-50. [PMID: 33241847 DOI: 10.1093/jalm/jfaa169] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 08/31/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Gender-affirming therapy with testosterone is commonly prescribed to aid in the masculinization of transgender men. Sex-hormone concentrations are routinely measured, but interpretation of results can be difficult due to the lack of published reference intervals. METHODS Healthy transgender individuals who had been prescribed testosterone (n = 82) for at least a year were recruited from internal medicine and primary care clinics that specialize in transgender medical care. Total testosterone and estradiol were measured using immunoassay and mass spectrometry; LH, FSH, SHBG, prolactin, progesterone, anti-Müllerian hormone (AMH), and dehydroepiandrosterone sulfate (DHEAS) were measured using immunoassay; free testosterone was calculated. Reference intervals (central 95%) were calculated according to Clinical Laboratory Standards Institute guidelines. RESULTS When evaluating general endocrine laboratory tests in people using masculinizing hormones, reference intervals for cisgender men can be applied for total and free testosterone and SHBG and reference intervals for cisgender women can be applied for prolactin. Reference intervals for estradiol, LH, FSH, AMH, and DHEAS differ from those used for cisgender men and cisgender women, and therefore should be interpreted using intervals specific to the transmasculine population. For testosterone and estradiol, results from immunoassays were clinically equivalent to mass spectrometry. CONCLUSION Masculinizing hormones will alter the concentrations of commonly evaluated endocrine hormones. Providers and laboratories should use appropriate reference intervals to interpret the results of these tests.
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Affiliation(s)
- Dina N Greene
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | | | | | | | - Katherine L Imborek
- Department of Family Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | - Julia C Drees
- The Permanente Medical Group Regional Laboratories, Richmond, CA
| | - Robert M Humble
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Nicole Nisly
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Nancy J Dole
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Susan K Dane
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Janice Frerichs
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA
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Mayhew AC, Gomez-Lobo V. Fertility Options for the Transgender and Gender Nonbinary Patient. J Clin Endocrinol Metab 2020; 105:5892794. [PMID: 32797184 PMCID: PMC7455280 DOI: 10.1210/clinem/dgaa529] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
Comprehensive care for transgender and gender nonbinary patients has been a priority established by the World Professional Association for Transgender Health. Because pubertal suppression, gender-affirming hormone therapy, and antiandrogen therapy used alone or in combination during medical transition can affect gonadal function, understanding the effects these treatments have on fertility potential is important for practitioners caring for transgender and gender nonbinary patients. In this review, we outline the impacts of gender-affirming treatments on fertility potential and discuss the counseling and the treatment approach for fertility preservation and/or family building in transgender and gender nonbinary individuals.
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Affiliation(s)
- Allison C Mayhew
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Children’s National Medical Center, Washington, DC
| | - Veronica Gomez-Lobo
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Children’s National Medical Center, Washington, DC
- Correspondence and Reprint Requests: Veronica Gomez-Lobo, MD, National Institute of Child Health and Human Development, Children’s National Medical Center, Division of Pediatric and Adolescent Gynecology, 10 Central Dr, Bldg 10, Rm 8N248, Bethesda, MD 20892, USA. E-mail:
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Dilaver N, Pellatt L, Jameson E, Ogunjimi M, Bano G, Homburg R, D Mason H, Rice S. The regulation and signalling of anti-Müllerian hormone in human granulosa cells: relevance to polycystic ovary syndrome. Hum Reprod 2020; 34:2467-2479. [PMID: 31735954 DOI: 10.1093/humrep/dez214] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 09/02/2019] [Indexed: 01/14/2023] Open
Abstract
STUDY QUESTION What prevents the fall in anti-Müllerian hormone (AMH) levels in polycystic ovary syndrome (PCOS) and what are the consequences of this for follicle progression in these ovaries? SUMMARY ANSWER Exposure of granulosa cells (GCs) to high levels of androgens, equivalent to that found in PCOS, prevented the fall in AMH and was associated with dysregulated AMH-SMAD signalling leading to stalled follicle progression in PCOS. WHAT IS KNOWN ALREADY In normal ovaries, AMH exerts an inhibitory role on antral follicle development and a fall in AMH levels is a prerequisite for ovulation. Levels of AMH are high in PCOS, contributing to the dysregulated follicle growth that is a common cause of anovulatory infertility in these women. STUDY DESIGN, SIZE, DURATION Human KGN-GC (the cell line that corresponds to immature GC from smaller antral follicles (AF)) were cultured with a range of doses of various androgens to determine the effects on AMH production. KGN-GC were also treated with PHTPP (an oestrogen receptor β (ERβ) antagonist) to examine the relationship between AMH expression and the ratio of ERα:ERβ. The differential dose-related effect of AMH on gene expression and SMAD signalling was investigated in human granulosa-luteal cells (hGLC) from women with normal ovaries, with polycystic ovarian morphology (PCOM) and with PCOS. KGN-GC were also cultured for a prolonged period with AMH at different doses to assess the effect on cell proliferation and viability. PARTICIPANTS/MATERIALS, SETTING, METHODS AMH protein production by cells exposed to androgens was measured by ELISA. The effect of PHTPP on the mRNA expression levels of AMH, ERα and ERβ was assessed by real-time quantitative PCR (qPCR). The influence of AMH on the relative mRNA expression levels of aromatase, AMH and its receptor AMHRII, and the FSH and LH receptor (FSHR and LHR) in control, PCOM and PCOS hGLCs was quantified by qPCR. Western blotting was used to assess changes in levels of SMAD proteins (pSMAD-1/5/8; SMAD-4; SMAD-6 and SMAD-7) after exposure of hGLCs from healthy women and women with PCOS to AMH. The ApoTox-Glo Triplex assay was used to evaluate the effect of AMH on cell viability, cytotoxicity and apoptosis. MAIN RESULTS AND THE ROLE OF CHANCE Testosterone reduced AMH protein secreted from KGN-GC at 10-9-10-7 M (P < 0.05; P < 0.005, multiple uncorrected comparisons Fishers least squares difference), but at equivalent hyperandrogenemic levels no change was seen in AMH levels. 5α-DHT produced a significant dose-related increase in AMH protein secreted into the media (P = 0.022, ANOVA). Increasing the mRNA ratio of ERα:ERβ produced a corresponding increase in AMH mRNA expression (P = 0.015, two-way ANOVA). AMH increased mRNA levels of aromatase (P < 0.05, one-way ANOVA) and FSHR (P < 0.0001, one-way ANOVA) in hGLCs from women with PCOM, but not from normal cells or PCOS (normal n = 7, PCOM n = 5, PCOS n = 4). In contrast to hGLCs from ovulatory ovaries, in PCOS AMH reduced protein levels (cell content) of stimulatory pSMAD-1/5/8 and SMAD-4 but increased inhibitory SMAD-6 and -7 (P < 0.05, normal n = 6, PCOS n = 3). AMH at 20 and 50 ng/ml decreased KGN-GC cell proliferation but not viability after 8 days of treatment (P < 0.005, two-way ANOVA). LARGE SCALE DATA N/A. LIMITATIONS, REASONS FOR CAUTION Luteinised GC from women undergoing IVF have a relatively low expression of AMH/AMHRII but advantageously continue to display responses inherent to the ovarian morphology from which they are collected. To compensate, we also utilised the KGN cell line which has been characterised to be at a developmental stage close to that of immature GC. The lack of flutamide influence on testosterone effects is not in itself sufficient evidence to conclude that the effect on AMH is mediated via conversion to oestrogen, and the effect of aromatase inhibitors or oestrogen-specific inhibitors should be tested. The effect of flutamide was tested on testosterone but not DHT. WIDER IMPLICATIONS OF THE FINDINGS Normal folliculogenesis and ovulation are dependent on the timely reduction in AMH production from GC at the time of follicle selection. Our findings reveal for the first time that theca-derived androgens may play a role in this model but that this inhibitory action is lost at levels of androgens equivalent to those seen in PCOS. The AMH decline may either be a direct effect of androgens or an indirect one via conversion to oestradiol and acting through the upregulation of ERα, which is known to stimulate the AMH promoter. Interestingly, the ability of GCs to respond to this continually elevated AMH level appears to be reduced in cells from women with PCOS due to an adaptive alteration in the SMAD signalling pathway and lower expression of AMHRII, indicating a form of 'AMH resistance'. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by the Thomas Addison Scholarship, St Georges Hospital Trust. The authors report no conflict of interest in this work and have nothing to disclose. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Nafi Dilaver
- Cell Biology and Genetics Research Centre, St George's University of London, London SW17 0RE, UK.,Academic Foundation Programme, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
| | - Laura Pellatt
- Cell Biology and Genetics Research Centre, St George's University of London, London SW17 0RE, UK.,Faculty of Engineering and Science, University of Greenwich, Chatham Maritime, Kent, ME4 4TB, UK
| | - Ella Jameson
- Biomedical Science Undergraduate Programme, St George's University of London, London SW17 0RE, UK
| | - Michael Ogunjimi
- Biomedical Science Undergraduate Programme, St George's University of London, London SW17 0RE, UK
| | - Gul Bano
- Thomas Addison Endocrine Unit, St George's Hospital, Cranmer Terrace, London SW17 0RE, UK
| | - Roy Homburg
- Homerton Fertility Unit, Homerton University Hospital, Homerton Row, London, UK
| | - Helen D Mason
- Cell Biology and Genetics Research Centre, St George's University of London, London SW17 0RE, UK
| | - Suman Rice
- Cell Biology and Genetics Research Centre, St George's University of London, London SW17 0RE, UK
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Fertility preservation options for transgender and gender-nonconforming individuals. Curr Opin Obstet Gynecol 2020; 31:170-176. [PMID: 30870185 DOI: 10.1097/gco.0000000000000537] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of androgen supplementation in ART with the most updated evidence, from animal studies to its clinical applications in poor ovarian responders (POR) and the future studies to be published. RECENT FINDINGS Animal studies, has shown that testosterone supplementation, can be an option to increase the recruitable follicular pool in POR. However, the potential mechanism of action, dose, and duration of treatment is still under investigation. Early studies in humans reported promising results in favor of androgens [dehydroepiandrosterone (DHEA) or testosterone] in POR. Nevertheless, recent evidence does not appear to follow the initial results, whereas the type, dose, and duration of testosterone administration appear to be crucial for treatment effect. SUMMARY Testosterone seems to play an essential role in regulating ovarian function. However, it is worrisome that androgens are used off-label, despite that the available evidence is weak. Although testosterone supplementation may be beneficial in POR, published studies have used inconsistent doses and duration of administration. An ongoing trial (T-TRANSPORT trial) for the first time aims to provide conclusive evidence on whether transdermal testosterone administration can improve the reproductive outcomes in patients undergoing IVF/ICSI.
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Ovarian stimulation outcomes among transgender men compared with fertile cisgender women. J Assist Reprod Genet 2020; 37:2463-2472. [PMID: 32719977 DOI: 10.1007/s10815-020-01902-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/23/2020] [Indexed: 12/30/2022] Open
Abstract
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.
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Grimstad FW, Fowler KG, New EP, Ferrando CA, Pollard RR, Chapman G, Gray M, Gomez Lobo V. Ovarian Histopathology in Transmasculine Persons on Testosterone: A Multicenter Case Series. J Sex Med 2020; 17:1807-1818. [PMID: 32703706 DOI: 10.1016/j.jsxm.2020.05.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/15/2020] [Accepted: 05/27/2020] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Frances W Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA, USA.
| | - Kylie G Fowler
- Department of Pediatric and Adolescent Gynecology, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Erika P New
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Cecile A Ferrando
- Center for Urogynecology and Pelvic Reconstructive Surgery, Center for LGBT Care, Cleveland Clinic, Cleveland, OH, USA
| | - Robert R Pollard
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center/MetroHealth Medical Center, Cleveland, OH, USA
| | - Graham Chapman
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center/MetroHealth Medical Center, Cleveland, OH, USA
| | - Meredith Gray
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Veronica Gomez Lobo
- Department of Pediatric and Adolescent Gynecology, National Institute for Child Health and Human Development, Bethesda, MA, USA
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Amir H, Oren A, Klochendler Frishman E, Sapir O, Shufaro Y, Segev Becker A, Azem F, Ben-Haroush A. Oocyte retrieval outcomes among adolescent transgender males. J Assist Reprod Genet 2020; 37:1737-1744. [PMID: 32430731 DOI: 10.1007/s10815-020-01815-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 05/10/2020] [Indexed: 12/16/2022] Open
Abstract
PURPOSE To compare fertility preservation (FP) outcomes among adolescent transgender males with those of cisgender females. METHODS This retrospective cohort study included nine adolescent transgender males and 39 adolescent cisgender females who underwent FP between January 2017-April 2019 and September 2013-April 2019, respectively. The transgender males were referred before initiating testosterone, and the cisgender females were referred due to cancer diagnosis before starting anticancer treatment. Statistical analyses compared assisted reproductive technology (ART) data and FP outcomes between two groups. RESULTS Basal FSH levels (5.4 ± 1.7 mIU/mL) and AFC (19.8 ± 5.6) of all transgender males were normal compared with standard references. The mean age of transgender males and cisgender females was similar (16.4 ± 1.1 vs 15.5 ± 1.3 years, respectively, P = 0.064). The amount of FSH used for stimulation was significantly lower among the former compared with the latter (2416 ± 1041 IU vs 4372 ± 1877 IU, P < 0.001), but the duration of stimulation was similar (12.6 ± 4.0 and 10.1 ± 2.8 days, P = 0.086). Peak estradiol level was significantly higher among transgender males compared with cisgender females (3073 ± 2637 pg/mL vs 1269 ± 975 pg/mL, respectively, P = 0.018), but there were no significant differences in number of retrieved oocytes between the two groups (30.6 ± 12.8 vs 22 ± 13.2, P = 0.091), number of MII oocytes (25.6 ± 12.9 vs 18.8 ± 11.2, P = 0.134), or maturity rates (81.5 ± 10.0% vs 85.4 ± 14.6%, P = 0.261). CONCLUSIONS Adolescent transgender males have an excellent response to ovulation stimulation before initiating testosterone treatment. Oocyte cryopreservation is, therefore, a feasible and effective way for them to preserve their fertility for future biological parenting.
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Affiliation(s)
- Hadar Amir
- Racine IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Asaf Oren
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emilie Klochendler Frishman
- IVF and Infertility Unit, Rabin Medical Center, Petach Tikva, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Onit Sapir
- IVF and Infertility Unit, Rabin Medical Center, Petach Tikva, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoel Shufaro
- IVF and Infertility Unit, Rabin Medical Center, Petach Tikva, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Segev Becker
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Foad Azem
- Racine IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Ben-Haroush
- IVF and Infertility Unit, Rabin Medical Center, Petach Tikva, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Amir H, Yaish I, Oren A, Groutz A, Greenman Y, Azem F. Fertility preservation rates among transgender women compared with transgender men receiving comprehensive fertility counselling. Reprod Biomed Online 2020; 41:546-554. [PMID: 32651108 DOI: 10.1016/j.rbmo.2020.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 04/18/2020] [Accepted: 05/06/2020] [Indexed: 11/25/2022]
Abstract
RESEARCH QUESTION What is the fertility preservation rate among transgender women who have received professional fertility counselling compared with transgender men? DESIGN This retrospective cohort study included 56 transgender women and 56 transgender men referred for comprehensive fertility counselling at the Gender Clinic of the Tel Aviv Sourasky Medical Center's Fertility Institute between January 2017 and April 2019. Statistical analyses were performed to compare transgender men with transgender women who preserved fertility and transgender people who preserved fertility and those that did not. RESULTS The fertility preservation rate of transgender women was significantly higher than that of transgender men (85.7% versus 35.7%, respectively, P < 0.001). The fertility preservation rate among transgender women was associated with being older and not having undergone gender-affirming hormone (GAH) treatment. The fertility preservation rate was higher among adolescent transgender boys compared with adolescent transgender girls (35% versus 6.25%, respectively, P = 0.005). The duration of GAH treatment among the transgender men who preserved fertility was 70 months compared with 18.6 months for transgender women (P = 0.05). All transgender boys opted for oocyte cryopreservation, while half of the transgender men who had not started GAH opted for oocyte cryopreservation, and half of those who had already started on GAH opted for embryo cryopreservation. CONCLUSIONS High fertility preservation rates among transgender individuals were found after comprehensive fertility counselling. Fertility preservation rates among adults were higher among transgender women compared with transgender men, while the opposite was found in transgender adolescents.
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Affiliation(s)
- Hadar Amir
- Racine IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Iris Yaish
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Oren
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asnat Groutz
- Racine IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yona Greenman
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Foad Azem
- Racine IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Fertility preservation in a transgender man without prolonged discontinuation of testosterone: a case report and literature review. F S Rep 2020; 1:43-47. [PMID: 34223211 PMCID: PMC8244337 DOI: 10.1016/j.xfre.2020.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/25/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Moravek MB, Kinnear HM, George J, Batchelor J, Shikanov A, Padmanabhan V, Randolph JF. Impact of Exogenous Testosterone on Reproduction in Transgender Men. Endocrinology 2020; 161:5762628. [PMID: 32105330 PMCID: PMC7046016 DOI: 10.1210/endocr/bqaa014] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 02/25/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Molly B Moravek
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- Correspondence: Molly B. Moravek, MD, MPH, Department of Obstetrics and Gynecology, Center for Reproductive Medicine, 475 Market Place, Building 1, Suite B, Ann Arbor, MI 48108. E-mail
| | - Hadrian M Kinnear
- Cellular and Molecular Biology Program, University of Michigan, Ann Arbor, Michigan
- Medical Scientist Training Program, University of Michigan, Ann Arbor, Michigan
| | - Jenny George
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | | | - Ariella Shikanov
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
- Cellular and Molecular Biology Program, University of Michigan, Ann Arbor, Michigan
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Vasantha Padmanabhan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan
| | - John F Randolph
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Dewailly D, Barbotin AL, Dumont A, Catteau-Jonard S, Robin G. Role of Anti-Müllerian Hormone in the Pathogenesis of Polycystic Ovary Syndrome. Front Endocrinol (Lausanne) 2020; 11:641. [PMID: 33013710 PMCID: PMC7509053 DOI: 10.3389/fendo.2020.00641] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/06/2020] [Indexed: 01/10/2023] Open
Abstract
Besides its interest for diagnosis, the finding of an elevated serum AMH level in PCOS has open major pathophysiological issues. This review addresses the three most important issues: 1- the role of AMH in the disturbed folliculogenesis of PCOS; 2- the role of AMH in the gonadotropin dysregulation of PCOS and 3- the role of AMH in the trans-generational transmission of PCOS. For each of those issues, the clinical and experimental evidences currently available are discussed and pathophysiological hypothesis are proposed.
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Affiliation(s)
- Didier Dewailly
- Inserm, Laboratory of Development and Plasticity of the Neuroendocrine Brain, Jean-Pierre Aubert Research Centre, Lille, France
- *Correspondence: Didier Dewailly
| | - Anne-Laure Barbotin
- Inserm, Laboratory of Development and Plasticity of the Neuroendocrine Brain, Jean-Pierre Aubert Research Centre, Lille, France
- CHU Lille, Institut de Biologie de la Reproduction-Spermiologie-CECOS, Hôpital Jeanne de Flandre, Lille, France
| | - Agathe Dumont
- CHU Lille, Unité Fonctionnelle de Gynécologie Endocrinienne, Service de Gynécologie Médicale, Orthogénie et Sexologie, Hôpital Jeanne de Flandre, Lille, France
- CHU Lille, Service d'Assistance Médicale à la Procréation et Préservation de la Fertilité, Hôpital Jeanne de Flandre, Lille, France
| | - Sophie Catteau-Jonard
- Inserm, Laboratory of Development and Plasticity of the Neuroendocrine Brain, Jean-Pierre Aubert Research Centre, Lille, France
- CHU Lille, Unité Fonctionnelle de Gynécologie Endocrinienne, Service de Gynécologie Médicale, Orthogénie et Sexologie, Hôpital Jeanne de Flandre, Lille, France
| | - Geoffroy Robin
- CHU Lille, Unité Fonctionnelle de Gynécologie Endocrinienne, Service de Gynécologie Médicale, Orthogénie et Sexologie, Hôpital Jeanne de Flandre, Lille, France
- CHU Lille, Service d'Assistance Médicale à la Procréation et Préservation de la Fertilité, Hôpital Jeanne de Flandre, Lille, France
- Lille University, EA 4308 “Gametogenesis and Gamete Quality”, Lille, France
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García-Acosta JM, San Juan-Valdivia RM, Fernández-Martínez AD, Lorenzo-Rocha ND, Castro-Peraza ME. Trans* Pregnancy and Lactation: A Literature Review from a Nursing Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 17:ijerph17010044. [PMID: 31861638 PMCID: PMC6981677 DOI: 10.3390/ijerph17010044] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/13/2019] [Accepted: 12/14/2019] [Indexed: 11/16/2022]
Abstract
Pregnancy and lactation involve two aspects that are socially and culturally associated with women. However, there are a few biological differences between male and female breast tissue. Lactation and pregnancy are viable processes that do not depend on sex. Even for the latter, it is only necessary to have an organ capable of gestation. Ways to favor mammogenesis and lactogenesis in trans* women have been established. There are protocols to promote lactation in trans* women, usually used for adoptive mothers or those whose children have been born through gestational surrogacy. Chestfeeding a baby could be the cause of feelings as diverse as gender dysphoria in the case of trans* men, and euphoria and affirmation of femininity in trans* women. This study involves a review of the available scientific literature addressing medical aspects related to pregnancy and lactation in trans* individuals, giving special attention to nursing care during perinatal care. There are scarce studies addressing care and specifically nursing care in trans* pregnancy and lactation. Our study indicates the factors that can be modified and the recommendations for optimizing the care provided to these individuals in order to promote and maintain the lactation period in search of improvement and satisfaction with the whole process.
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Affiliation(s)
- Jesús Manuel García-Acosta
- Faculty of Nursing, University of La Laguna, Canary Islands Public Health Service, 38010 Tenerife, Canary Islands, Spain
- Correspondence: ; Tel.: +34-6-8700-7510
| | | | - Alfredo David Fernández-Martínez
- Department of Education Counseling Universities, Culture and Sports, Government of the Canary Islands, 38010 Tenerife, Canary Islands, Spain;
| | - Nieves Doria Lorenzo-Rocha
- The Faculty of Nursing Nª Sª de La Candelaria, University of La Laguna, Canary Islands Public Health Service, 38010 Tenerife, Canary Islands, Spain; (N.D.L.-R.); (M.E.C.-P.)
| | - Maria Elisa Castro-Peraza
- The Faculty of Nursing Nª Sª de La Candelaria, University of La Laguna, Canary Islands Public Health Service, 38010 Tenerife, Canary Islands, Spain; (N.D.L.-R.); (M.E.C.-P.)
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Humble RM, Imborek KL, Nisly N, Greene DN, Krasowski MD. Common Hormone Therapies Used to Care for Transgender Patients Influence Laboratory Results. J Appl Lab Med 2019; 3:799-814. [DOI: 10.1373/jalm.2018.027078] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023]
Abstract
Abstract
Background
Many laboratory tests are reported and interpreted with sex-specific reference intervals. However, transgender individuals receiving masculinizing or feminizing hormone therapy experience physiological changes predisposing some laboratory tests to shift outside of existing reference intervals. In this study, we review laboratory testing of a large cohort of transgender individuals who were prescribed hormone therapy for at least 6 months at an academic medical center.
Methods
Transgender patients were identified using a search function within the electronic health record with gender identity status verified by chart review. Patients were grouped based on type of hormone therapy administered. All laboratory studies were ordered for medical purposes as part of clinical care; as a result, the exact laboratory tests differed among the patients. Some of the patients had sufficient data for both 6- and 12-month comparisons with baseline laboratory values.
Results
Statistically significant changes were observed at 6- and 12-month comparisons in basic chemistry, endocrine, and hematologic parameters for transgender individuals receiving masculinizing or feminizing hormones. Chart review demonstrated variation in route of administration of hormone therapy and frequency of gender-affirming surgery within the study population.
Conclusions
Transgender individuals receiving hormone therapy experienced significant changes in components of basic chemistry, endocrine, and hematologic parameters following administration of hormone therapy. Variability in hormone dosing and route of administration for gender-affirming treatment warrants further investigation.
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Affiliation(s)
- Robert M Humble
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Katherine L Imborek
- Department of Family Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Nicole Nisly
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Dina N Greene
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Matthew D Krasowski
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA
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Baram S, Myers SA, Yee S, Librach CL. Fertility preservation for transgender adolescents and young adults: a systematic review. Hum Reprod Update 2019; 25:694-716. [DOI: 10.1093/humupd/dmz026] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/21/2019] [Accepted: 07/14/2019] [Indexed: 12/17/2022] Open
Abstract
Abstract
BACKGROUND
Many transgender individuals choose to undergo gender-affirming hormone treatment (GAHT) and/or sex reassignment surgery (SRS) to alleviate the distress that is associated with gender dysphoria. Although these treatment options often succeed in alleviating such symptoms, they can also negatively impact future reproductive potential.
OBJECTIVE AND RATIONALE
The purpose of this systematic review was to synthesize the available psychosocial and medical literature on fertility preservation (FP) for transgender adolescents and young adults (TAYAs), to identify gaps in the current research and provide suggestions for future research directions.
SEARCH METHODS
A systematic review of English peer-reviewed papers published from 2001 onwards, using the preferred reporting items for systematic reviews and meta-analyses protocols (PRISMA-P) guidelines, was conducted. Four journal databases (Ovid MEDLINE, PubMed Medline, Ovid Embase and Ovid PsychINFO) were used to identify all relevant studies exploring psychosocial or medical aspects of FP in TAYAs. The search strategy used a combination of subject headings and generic terms related to the study topic and population. Bibliographies of the selected articles were also hand searched and cross-checked to ensure comprehensive coverage. All selected papers were independently reviewed by the co-authors. Characteristics of the studies, objectives and key findings were extracted, and a systematic review was conducted.
OUTCOMES
Included in the study were 19 psychosocial-based research papers and 21 medical-based research papers that explore fertility-related aspects specific for this population. Key psychosocial themes included the desire to have children for TAYAs; FP discussions, counselling and referrals provided by healthcare providers (HCPs); FP utilization; the attitudes, knowledge and beliefs of TAYAs, HCPs and the parents/guardians of TAYAs; and barriers to accessing FP. Key medical themes included fertility-related effects of GAHT, FP options and outcomes. From a synthesis of the literature, we conclude that there are many barriers preventing TAYAs from pursuing FP, including a lack of awareness of FP options, high costs, invasiveness of the available procedures and the potential psychological impact of the FP process. The available medical data on the reproductive effects of GAHT are diverse, and while detrimental effects are anticipated, the extent to which these effects are reversible is unknown.
WIDER IMPLICATIONS
FP counselling should begin as early as possible as a standard of care before GAHT to allow time for informed decisions. The current lack of high-quality medical data specific to FP counselling practice for this population means there is a reliance on expert opinion and extrapolation from studies in the cisgender population. Future research should include large-scale cohort studies (preferably multi-centered), longitudinal studies of TAYAs across the FP process, qualitative studies of the parents/guardians of TAYAs and studies evaluating the effectiveness of different strategies to improve the attitudes, knowledge and beliefs of HCPs.
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Affiliation(s)
- Shira Baram
- Create Fertility Centre, 790 Bay Street, Suite 1100, Toronto, Ontario M5G 1N8, Canada
- Department of Obstetrics and Gynecology, University of Toronto, 27 King’s College Circle, Toronto, Ontario M5S, Canada
| | - Samantha A Myers
- Create Fertility Centre, 790 Bay Street, Suite 1100, Toronto, Ontario M5G 1N8, Canada
- McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8, Canada
| | - Samantha Yee
- Create Fertility Centre, 790 Bay Street, Suite 1100, Toronto, Ontario M5G 1N8, Canada
| | - Clifford L Librach
- Create Fertility Centre, 790 Bay Street, Suite 1100, Toronto, Ontario M5G 1N8, Canada
- Department of Obstetrics and Gynecology, University of Toronto, 27 King’s College Circle, Toronto, Ontario M5S, Canada
- Department of Physiology, University of Toronto, 27 King’s College Circle, Toronto, Ontario M5S, Canada
- Institute of Medical Science, University of Toronto, 27 King’s College Circle, Toronto, Ontario M5S, Canada
- Department of Obstetrics and Reproductive Endocrinology, Sunnybrook Health Sciences Centre; 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
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Adeleye AJ, Cedars MI, Smith J, Mok-Lin E. Ovarian stimulation for fertility preservation or family building in a cohort of transgender men. J Assist Reprod Genet 2019; 36:2155-2161. [PMID: 31435820 DOI: 10.1007/s10815-019-01558-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 08/06/2019] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The purpose of this study was to compare ovarian stimulation and pregnancy outcomes between transgender men (1) with and without a history of testosterone use (HRT) and (2) to cisgender women. METHODS Retrospective chart review between January 1st 2015 and March 1st, 2019 of transgender men and cisgender women seeking ovarian stimulation (OS) matched by BMI and age. Outcomes were compared using Fisher's exact or Wilcoxon's rank sum tests. RESULTS Thirteen transgender men presented for OS, 7 who used HRT. When comparing transgender men with and without a history of HRT, there were no differences in the baseline follicle count, cycle length, or FSH and hmG used (p = 0.193, 0.306, 0.200, and 0.197, respectively). Transgender men who used HRT had lower peak estradiol and oocytes retrieved compared to transgender men with no HRT use; peak estradiol levels of 1175 pg/mL IQR [559.5-2684]) vs 2713.5 pg/mL IQR [2335-3105]; oocytes retrieved 12 IQR [4-26]) vs. 25.5 [18-28] (p = 0.046. and 0.038, respectively). There were no differences in the estradiol level per oocyte, meiosis II oocyte yield, or maturity rate (MII/oocytes) between the two groups (p = 1.000, 0.148, and 0.147, respectively). Peak estradiol levels were lower among transgender men compared to cisgender women (p = 0.016), but the remaining cycle characteristics were similar between the two groups. Three successful pregnancies were conceived using the oocytes of transgender men who used HRT. CONCLUSION HRT use may not negatively impact ovarian stimulation outcomes. Clinical pregnancies are possible from the oocytes of transgender men with a history of HRT.
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Affiliation(s)
- Amanda J Adeleye
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th St, 7th floor, San Francisco, CA, 94107, USA.
| | - Marcelle I Cedars
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th St, 7th floor, San Francisco, CA, 94107, USA
| | - James Smith
- Department of Urology, University of California San Francisco, 400 Parnassus Ave, San Francisco, CA, 94117, USA
| | - Evelyn Mok-Lin
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th St, 7th floor, San Francisco, CA, 94107, USA
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Wang Z, Feng M, Awe O, Ma Y, Shen M, Xue P, Ahima R, Wolfe A, Segars J, Wu S. Gonadotrope androgen receptor mediates pituitary responsiveness to hormones and androgen-induced subfertility. JCI Insight 2019; 5:127817. [PMID: 31393859 DOI: 10.1172/jci.insight.127817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Many women with hyperandrogenemia suffer from irregular menses and infertility. However, it is unknown whether androgens directly affect reproduction. Since animal models of hyperandrogenemia-induced infertility are associated with obesity, which may impact reproductive function, we have created a lean mouse model of elevated androgen using implantation of low dose dihydrotestosterone (DHT) pellets to separate the effects of elevated androgen from obesity. The hypothalamic-pituitary-gonadal axis controls reproduction. While we have demonstrated that androgen impairs ovarian function, androgen could also disrupt neuroendocrine function at the level of brain and/or pituitary to cause infertility. To understand how elevated androgens might act on pituitary gonadotropes to influence reproductive function, female mice with disruption of the androgen receptor (Ar) gene specifically in pituitary gonadotropes (PitARKO) were produced. DHT treated control mice with intact pituitary Ar (Con-DHT) exhibit disrupted estrous cyclicity and fertility with reduced pituitary responsiveness to GnRH at the level of both calcium signaling and LH secretion. These effects were ameliorated in DHT treated PitARKO mice. Calcium signaling controls GnRH regulation of LH vesicle exotocysis. Our data implicated upregulation of GEM (a voltage-dependent calcium channel inhibitor) in the pituitary as a potential mechanism for androgen's pathological effects. These results demonstrate that gonadotrope AR, as an extra-ovarian regulator, plays an important role in reproductive pathophysiology.
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Affiliation(s)
- Zhiqiang Wang
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mingxiao Feng
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olubusayo Awe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yaping Ma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Mingjie Shen
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Gynecology and Obstetrics, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ping Xue
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Andrew Wolfe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Molecular and Cellular Physiology, and
| | - James Segars
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheng Wu
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Molecular and Cellular Physiology, and.,Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abstract
Hormonal therapy and gender-affirming surgeries in transgender people have known deleterious impacts on future fertility using one's own gametes. This review focuses on fertility preservation, including the effects of medical hormone treatment on fertility, available and experimental options of fertility preservation in transgender adults, including sperm cryopreservation for transwomen and oocyte cryopreservation for transmen, and options for prepubertal transgender adolescents, including testicular and ovarian tissue cryopreservation. Transgender patients continue to face barriers and receive infrequent counseling regarding fertility preservation. Physicians should ideally counsel and discuss fertility preservation options before transgender patients undergo hormone therapy of gender-affirmation surgery.
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Affiliation(s)
- Michael F Neblett
- Department of Gynecology and Obstetrics, Emory University, Emory University School of Medicine, Glenn Building, 4th Floor-412 B, 69 Jesse Hill Jr. Drive Southeast, Atlanta, GA 30303, USA
| | - Heather S Hipp
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, 550 Peachtree Street, Suite 1800, Atlanta, GA 30308, USA.
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43
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Abstract
There are an estimated 1.4 million transgender adults in the United States, and lack of providers knowledgeable in transgender care is a barrier to health care. Obstetricians and Gynecologists can help increase access in part by becoming competent in gender-affirming hormone therapy. For transgender men, testosterone protocols can be extrapolated from those used for hypogonadal cisgender men. Unfortunately, there are not any high-quality, long-term prospective studies on the effectiveness and safety of different testosterone regimens specifically in transgender men, but the available data suggest that gender-affirming testosterone therapy is safe and effective with proper screening and monitoring.
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de Castro-Peraza ME, García-Acosta JM, Delgado-Rodriguez N, Sosa-Alvarez MI, Llabrés-Solé R, Cardona-Llabrés C, Lorenzo-Rocha ND. Biological, Psychological, Social, and Legal Aspects of Trans Parenthood Based on a Real Case-A Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16060925. [PMID: 30875835 PMCID: PMC6466010 DOI: 10.3390/ijerph16060925] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/11/2019] [Accepted: 03/11/2019] [Indexed: 01/01/2023]
Abstract
Trans men are people who, based on their genitals, were assigned the status of female at birth. However, their identity and their way of living gender do not correspond to the socially established norms. In this paper, we discuss the different perspectives in relation to transgender people and their desire for parenthood. This review, and the basis of this paper, is inspired by the case of a trans man who desired gestation with his own genetic material. He began the cycle of assisted reproduction when he was a legally recognized woman, but that attempt ended with a miscarriage. From that assisted reproduction cycle, four embryos remained frozen. After the failed experience of gestation, the person completed his transition. Now legally a man, he attempted to gestate using his reproductive organs. This literature review aimed to identify relevant studies describing the relationship between transgender person and biological parenthood. This study comprehensively addresses important aspects one should know when considering a transgender pregnancy. These factors include biological, psychological, social, and legal issues. After reviewing the state-of-the-art information on trans parenthood, the main conclusion is that ‘the desire to have a child is not a male or female desire but a human desire’.
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Affiliation(s)
| | | | | | | | - Rosa Llabrés-Solé
- Faculty of Nursing N. S. Candelaria, University of La Laguna, 38010, Tenerife, Canary Islands, Spain.
| | - Carla Cardona-Llabrés
- Faculty of Nursing N. S. Candelaria, University of La Laguna, 38010, Tenerife, Canary Islands, Spain.
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Tishelman AC, Sutter ME, Chen D, Sampson A, Nahata L, Kolbuck VD, Quinn GP. Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: qualitative responses to an international survey. J Assist Reprod Genet 2019; 36:579-588. [PMID: 30604136 PMCID: PMC6439053 DOI: 10.1007/s10815-018-1395-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/18/2018] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To examine provider perceptions of practice behaviors and barriers related to fertility counseling, fertility preservation, and family building among transgender patients. METHODS Participants were medical and mental health professionals who treat adult and youth transgender patients. Recruitment occurred online and in person, via professional listservs for transgender professionals, conferences, and gender clinics. From August-November 2017, 110 participants representing nine countries responded to four open-ended questions included on a survey related to provider practice behaviors and perceived barriers to fertility counseling, fertility preservation, and family building with transgender patients. Thematic coding analysis was used to identify themes. RESULTS Multiple themes were identified including the following: access and cost issues; urgency for gender-affirming treatment; patient maturity and inability to make future-oriented decisions; and provider-related challenges pertaining to knowledge, role, and general lack of information in the nascent field of transgender reproductive health. CONCLUSION(S) This study yielded insights into practice behaviors, challenges, and perceived barriers to fertility counseling with transgender individuals and can serve as a basis for intervention development to optimize clinical practices with this population.
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Affiliation(s)
- Amy C Tishelman
- Departments of Endocrinology and Psychiatry, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, 02115, USA.
| | - Megan E Sutter
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, 33612, USA
| | - Diane Chen
- Division of Adolescent Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
- Department of Child and Adolescent Psychiatry, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
- Departments of Psychiatry and Behavioral Sciences, and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Amani Sampson
- Departments of OB-GYN and Population Health, New York University School of Medicine, New York, NY, 10016, USA
| | - Leena Nahata
- Division of Endocrinology and Center for Biobehavioral Health, Nationwide Children's Hospital, Columbus, OH, 43205, USA
- The Ohio State University College of Medicine, Columbus, OH, 43205, USA
| | - Victoria D Kolbuck
- Division of Adolescent Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
| | - Gwendolyn P Quinn
- Departments of OB-GYN and Population Health, New York University School of Medicine, New York, NY, 10016, USA
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T'Sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of Transgender Medicine. Endocr Rev 2019; 40:97-117. [PMID: 30307546 DOI: 10.1210/er.2018-00011] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 06/21/2018] [Indexed: 02/08/2023]
Abstract
Gender-affirming treatment of transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological, and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen-lowering medications. Feminizing treatment with estrogens and antiandrogens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth, and fat redistribution in a female pattern. Possible side effects should be discussed with patients, particularly those at risk for venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses, and increases of muscle mass and facial and body hair. Owing to the lack of evidence, treatment of gender nonbinary people should be individualized. Young people may receive pubertal suspension, consisting of GnRH analogs, later followed by sex steroids. Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid-related malignancies can occur but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to the effect of gender-affirming treatment in the nonbinary population.
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Affiliation(s)
- Guy T'Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium.,Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Jon Arcelus
- Institute of Mental Health, Jubilee Campus, University of Nottingham, Nottingham, United Kingdom.,Nottingham Centre for Transgender Health, Nottingham, United Kingdom
| | - Louis Gooren
- University Hospital, Vrije Universiteit of Amsterdam, Amsterdam, Netherlands
| | | | - Vin Tangpricha
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University, Atlanta, Georgia
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Nahata L, Chen D, Moravek MB, Quinn GP, Sutter ME, Taylor J, Tishelman AC, Gomez-Lobo V. Understudied and Under-Reported: Fertility Issues in Transgender Youth-A Narrative Review. J Pediatr 2019; 205:265-271. [PMID: 30293639 DOI: 10.1016/j.jpeds.2018.09.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/14/2018] [Accepted: 09/05/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Leena Nahata
- Nationwide Children's Hospital/The Ohio State University, Columbus, OH.
| | - Diane Chen
- Ann and Robert H. Lurie Children's Hospital/Northwestern University, Chicago, IL
| | | | | | - Megan E Sutter
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | - Amy C Tishelman
- Boston Children's Hospital/Harvard Medical School, Boston, MA
| | - Veronica Gomez-Lobo
- Washington Hospital Center/Children's National Medical Center/Georgetown University, Washington, DC
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Schagen SEE, Lustenhouwer P, Cohen-Kettenis PT, Delemarre-van de Waal HA, Hannema SE. Changes in Adrenal Androgens During Puberty Suppression and Gender-Affirming Hormone Treatment in Adolescents With Gender Dysphoria. J Sex Med 2018; 15:1357-1363. [PMID: 30224022 DOI: 10.1016/j.jsxm.2018.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 07/15/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Gender-affirming hormone treatment is known to affect adrenal androgen levels in adult individuals with gender dysphoria (GD). This may be clinically relevant because the adrenal gland plays a critical role in many different metabolic processes. AIM This study aims to assess the effects of gonadotropin-releasing hormone analogs (GnRHa) treatment and gender-affirming hormone treatment on adrenal androgen levels in adolescents with GD. METHODS In this prospective study, dehydroepiandrosterone-sulfate (DHEAS) and androstenedione values were measured every 6 months during 2 years of GnRHa treatment only, and 2 years of GnRHa combined with gender-affirming hormone treatment (estradiol or testosterone) in 73 transgirls and 54 transboys. To determine trends in adrenal androgen levels a linear mixed model was used to approximate androgen levels. MAIN OUTCOME MEASURES DHEAS and androstenedione levels were the main outcome measures. RESULTS DHEAS levels rose in transboys during GnRHa treatment, which may represent the normal increase during adolescence. In transgirls no change in DHEAS levels during GnRHa treatment was found. Gender-affirming hormone treatment did not affect DHEAS levels in either sex. In transboys androstenedione levels decreased during the first year of GnRHa treatment, which may reflect reduced ovarian androstenedione synthesis, and rose during the first year of gender-affirming hormone treatment, possibly due to conversion of administered testosterone. In transgirls androstenedione levels did not change during either GnRHa or gender-affirming hormone treatment. CLINICAL IMPLICATIONS No deleterious effects of treatment on adrenal androgen levels were found during approximately 4 years of follow-up. STRENGTHS & LIMITATIONS This is one of the largest cohort of adolescents with GD, treated using a uniform protocol, with standardized follow-up. The lack of a control group is a limitation. CONCLUSION The changes in androstenedione levels during GnRHa and gender-affirming hormone treatment in transboys may not be of adrenal origin. The absence of changes in androstenedione levels in transgirls or DHEAS levels in either sex during gender-affirming hormone treatment suggests that gender-affirming hormone treatment does not significantly affect adrenal androgen production. Schagen SEE, Lustenhouwer P, Cohen-Kettenis PT, et al. Changes in Adrenal Androgens During Puberty Suppression and Gender-Affirming Hormone Treatment in Adolescents With Gender Dysphoria. J Sex Med 2018;15:1357-1363.
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Affiliation(s)
- Sebastian E E Schagen
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands; Department of Pediatric Endocrinology, VU University Medical Center, Amsterdam, The Netherlands
| | - Paul Lustenhouwer
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology and Medical Social Work, VU University Medical Center, Amsterdam, The Netherlands
| | - Henriette A Delemarre-van de Waal
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands; Department of Pediatric Endocrinology, VU University Medical Center, Amsterdam, The Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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Pierre A, Taieb J, Giton F, Grynberg M, Touleimat S, El Hachem H, Fanchin R, Monniaux D, Cohen-Tannoudji J, di Clemente N, Racine C. Dysregulation of the Anti-Müllerian Hormone System by Steroids in Women With Polycystic Ovary Syndrome. J Clin Endocrinol Metab 2017; 102:3970-3978. [PMID: 28938480 DOI: 10.1210/jc.2017-00308] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 08/11/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Anti-Müllerian hormone (AMH) and AMH type II receptor (AMHR2) are overexpressed in granulosa cells (GCs) from women with polycystic ovary syndrome (PCOS), the most common cause of female infertility. OBJECTIVE The aim of the study was to compare the regulation of the AMH/AMHR2 system by 5α-dihydrotestosterone (5α-DHT) and estradiol (E2) in GCs from control subjects and women with PCOS. DESIGN, SETTING, PATIENTS Experiments were performed on follicular fluids (FF) and GCs from women undergoing in vitro fertilization. MAIN OUTCOME MEASURES FF steroid levels were measured by mass spectrometry, and messenger RNA (mRNA) accumulation was quantified by reverse transcription real-time polymerase chain reaction. RESULTS Total testosterone (T), free T, and 5α-DHT FF levels were significantly higher (P < 0.001) in women with PCOS than in controls. However, E2 and sex hormone-binding globulin concentrations were comparable between the two groups. In GCs from control women, the AMH and AMHR2 expression were not affected by 5α-DHT treatment, whereas AMH mRNA levels were upregulated by 5α-DHT in GCs from patients with PCOS (2.3-fold, P < 0.01) overexpressing the androgen receptor (1.4-fold, P < 0.05). E2 downregulated the AMH and AMHR2 expression in GCs from control women (1.4-fold, P < 0.001 and 1.8-fold, P < 0.01, respectively) but had no effect on these genes in GCs from women with PCOS. This differential effect of E2 was associated with a higher estrogen receptor 1 expression in GCs from women with PCOS (1.9-fold, P < 0.05). CONCLUSIONS In GCs from women with PCOS, the regulation of AMH and AMHR2 expression is altered in a way that promotes the overexpression of the AMH/AMHR2 system, and could contribute to the follicular arrest observed in these patients.
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Affiliation(s)
- Alice Pierre
- Université Paris Diderot, Sorbonne Paris Cité, F-75013 Paris, France
- Institut National de la Santé et de la Recherche Médicale Unité 1133, Physiologie de l'Axe Gonadotrope, F-75013 Paris, France
- Centre National de la Recherche Scientifique, UMR8251, Biologie Fonctionnelle et Adaptative, F-75013 Paris, France
| | - Joëlle Taieb
- Université Paris Diderot, Sorbonne Paris Cité, F-75013 Paris, France
- Institut National de la Santé et de la Recherche Médicale Unité 1133, Physiologie de l'Axe Gonadotrope, F-75013 Paris, France
- Centre National de la Recherche Scientifique, UMR8251, Biologie Fonctionnelle et Adaptative, F-75013 Paris, France
| | - Frank Giton
- Assistance Publique-Hôpitaux de Paris, Centre d'Investigations Biologiques GHU, INSERM IMRB U955, Centre de Recherche Chirurgicales, Hopital Henri Mondor, Créteil F-94010, France
| | - Michaël Grynberg
- Université Paris Diderot, Sorbonne Paris Cité, F-75013 Paris, France
- Institut National de la Santé et de la Recherche Médicale Unité 1133, Physiologie de l'Axe Gonadotrope, F-75013 Paris, France
- Centre National de la Recherche Scientifique, UMR8251, Biologie Fonctionnelle et Adaptative, F-75013 Paris, France
| | - Salma Touleimat
- Université Paris Diderot, Sorbonne Paris Cité, F-75013 Paris, France
- Institut National de la Santé et de la Recherche Médicale Unité 1133, Physiologie de l'Axe Gonadotrope, F-75013 Paris, France
- Centre National de la Recherche Scientifique, UMR8251, Biologie Fonctionnelle et Adaptative, F-75013 Paris, France
| | - Hady El Hachem
- Université Paris Diderot, Sorbonne Paris Cité, F-75013 Paris, France
- Institut National de la Santé et de la Recherche Médicale Unité 1133, Physiologie de l'Axe Gonadotrope, F-75013 Paris, France
- Centre National de la Recherche Scientifique, UMR8251, Biologie Fonctionnelle et Adaptative, F-75013 Paris, France
| | - Renato Fanchin
- Université Paris Diderot, Sorbonne Paris Cité, F-75013 Paris, France
- Institut National de la Santé et de la Recherche Médicale Unité 1133, Physiologie de l'Axe Gonadotrope, F-75013 Paris, France
- Centre National de la Recherche Scientifique, UMR8251, Biologie Fonctionnelle et Adaptative, F-75013 Paris, France
| | - Danielle Monniaux
- Institut National de la Recherche Agronomique, UMR85 Physiologie de la Reproduction et des Comportements, F-37380 Nouzilly, France
- Centre National de la Recherche Scientifique, UMR7247, F-37380 Nouzilly, France
- Université François Rabelais de Tours, F-37041 Tours, France
- Institut Français du Cheval et de l'Equitation, F-37380 Nouzilly, France
| | - Joëlle Cohen-Tannoudji
- Université Paris Diderot, Sorbonne Paris Cité, F-75013 Paris, France
- Institut National de la Santé et de la Recherche Médicale Unité 1133, Physiologie de l'Axe Gonadotrope, F-75013 Paris, France
- Centre National de la Recherche Scientifique, UMR8251, Biologie Fonctionnelle et Adaptative, F-75013 Paris, France
| | - Nathalie di Clemente
- Université Paris Diderot, Sorbonne Paris Cité, F-75013 Paris, France
- Institut National de la Santé et de la Recherche Médicale Unité 1133, Physiologie de l'Axe Gonadotrope, F-75013 Paris, France
- Centre National de la Recherche Scientifique, UMR8251, Biologie Fonctionnelle et Adaptative, F-75013 Paris, France
| | - Chrystèle Racine
- Université Paris Diderot, Sorbonne Paris Cité, F-75013 Paris, France
- Institut National de la Santé et de la Recherche Médicale Unité 1133, Physiologie de l'Axe Gonadotrope, F-75013 Paris, France
- Centre National de la Recherche Scientifique, UMR8251, Biologie Fonctionnelle et Adaptative, F-75013 Paris, France
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50
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Broughton D, Omurtag K. Care of the transgender or gender-nonconforming patient undergoing in vitro fertilization. Int J Transgend 2017. [DOI: 10.1080/15532739.2017.1352554] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Darcy Broughton
- Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kenan Omurtag
- Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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