Access to fertility services by transgender and nonbinary persons: an Ethics Committee opinion

An Analysis of Fertility Preservation Offerings for Transgender Youth on United States Pediatric Hospital Websites

PURPOSE

To survey United States (U.S.) pediatric hospital websites for information about fertility preservation (FP) for transgender patients. Secondarily, to identify hospital characteristics associated with higher likelihood of publishing transgender-specific FP content on websites.

METHODS

This cross-sectional study included all U.S. pediatric hospitals from Children's Hospital Association excluding specialty hospitals. From September-December 2023, 2 independent researchers surveyed websites for: geographic location, academic affiliation, religious affiliation, presence of general and transgender-specific FP information, and specialties of FP providers. Fisher's exact and Pearson's Chi-square tests were used.

RESULTS

Of 177 websites surveyed, 41% (n = 73) published FP information, largely targeted to oncology patients (90%, n = 66). Only 8% (n = 15) of all websites mentioned FP for transgender youth. Based on website information, most fertility programs included a medical oncologist (80%, n = 53); fewer included a urologist (32%, n = 21), pediatric gynecologist (27%, n = 18) or reproductive endocrinologist (RE, 21%, n = 14). About half (n = 31) referred to affiliate REs. Presence of transgender-specific FP website content ranged from 0% to 5% in Southern divisions to 20% in New England (median = 10%). Secular (p < .001) and academic (p = .04) hospital websites were significantly more likely to include FP content.

DISCUSSION

Our findings highlight a gap in access to FP information for transgender youth on U.S. pediatric hospital websites. Few websites identify FP teams that include an RE or pediatric gynecologist, who specialize in FP for patients with ovaries. Access to FP information is critical to transgender youth who may desire genetically related children later in life. Strategies to assure this information is widely available are needed.

Infertility: Disparities and Access to Services: ACOG Committee Statement No. 14

Diagnostic testing and treatment for infertility should be available to everyone in need of these services. The disparities in rates of infertility and the barriers to accessing assisted reproductive technology services should be understood through and addressed within a reproductive justice framework. Obstetrician-gynecologists and other health care professionals should identify specific populations at risk and their accompanying barriers to access to help improve infertility care across populations. Health care professionals should ask appropriate questions about social and structural drivers of health that may influence a patient's health and use of the health care system to better understand their patients' needs and lived experiences. Obstetrician-gynecologists and other health care professionals should advocate for insurance coverage for infertility services, including assisted reproductive technology; policy changes that promote comprehensive reproductive health; and evidence-based, lower cost treatment options.

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

BACKGROUND

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Klinefelter syndrome: etiology and clinical considerations in male infertility†

Klinefelter syndrome (KS) is the most prevalent chromosomal disorder occurring in males. It is defined by an additional X chromosome, 47,XXY, resulting from errors in chromosomal segregation during parental gametogenesis. A major phenotype is impaired reproductive function, in the form of low testosterone and infertility. This review comprehensively examines the genetic and physiological factors contributing to infertility in KS, in addition to emergent assisted reproductive technologies, and the unique ethical challenges KS patients face when seeking infertility treatment. The pathology underlying KS is increased susceptibility for meiotic errors during spermatogenesis, resulting in aneuploid or even polyploid gametes. Specific genetic elements potentiating this susceptibility include polymorphisms in checkpoint genes regulating chromosomal synapsis and segregation. Physiologically, the additional sex chromosome also alters testicular endocrinology and metabolism by dysregulating interstitial and Sertoli cell function, collectively impairing normal sperm development. Additionally, epigenetic modifications like aberrant DNA methylation are being increasingly implicated in these disruptions. We also discuss assisted reproductive approaches leveraged in infertility management for KS patients. Application of assisted reproductive approaches, along with deep comprehension of the meiotic and endocrine disturbances precipitated by supernumerary X chromosomes, shows promise in enabling biological parenthood for KS individuals. This will require continued multidisciplinary collaboration between experts with background of genetics, physiology, ethics, and clinical reproductive medicine.

Reproductive Considerations in the Transgender and Gender Diverse Population: A Review

Many transgender and gender diverse (TGD) individuals will be considering gender-affirming treatments during their reproductive lifespan. These medically necessary treatments have a negative impact on reproductive potential. All TGD individuals should be counseled regarding fertility. Options for fertility preservation for individuals who have undergone puberty include mature oocyte, embryo, and sperm cryopreservation. In prepubertal individuals, ovarian tissue cryopreservation may be considered, but testicular tissue cryopreservation remains experimental only. While there have been advances in the technology and standardization of reproductive health care for this population, many gaps remain in our knowledge which require further research.

The Importance of Fertility Preservation in the Transgender Population

OBJECTIVE

To call to attention the often-overlooked aspect of pediatric transgender care: the importance of fertility preservation prior to instituting gender-affirming therapy. The transgender population has long been marginalized by society. Societal stigmata, fear to seek care, and dearth of provider knowledge regarding transgender health issues have caused disparities to widen. Gender-affirming procedures and hormone therapy affect the long-term reproductive potential of transgender individuals. While cost concerns and insurance coverage regarding oncofertility is a prominent area of discussion, the transgender community is often excluded.

METHODS

Sixteen genetically XY females, followed by their multidisciplinary transgender care teams, were interested in starting hormone therapy due to impending onset and/or progression of puberty. Their physicians were aware of fertility struggles after undergoing hormone therapy and therefore referred to urology. Sperm cryopreservation via open gonadal biopsy, testicular tissue cryopreservation (TTC), and semen sample (when age/maturity-appropriate) were discussed. Though requiring surgery, biopsy/TTC relieves patients of the psychological impact of semen sample production.

RESULTS

Under IRB approval, 15 patients (median age 12 years, range 10-16 years) underwent TTC (Fig. 1). One patient (aged years) opted for semen sample. All patients had success with spermatogonial stem cells cryopreserved for future patient use.

CONCLUSION

With more individuals beginning medical and surgical therapy at a younger age, fertility preservation discussions are essential but often overlooked, depriving these individuals the joy of becoming a biological parent. TTC can be safely done in pediatric populations, though research is necessary to expand beyond current experimental stage of tissue development.

Reflecting on the Importance of Family Building and Fertility Preservation: Transgender People's Experiences with Starting Gender-Affirming Treatment as an Adolescent

Purpose

We aimed to investigate how adults, who started gender-affirming hormone treatment during adolescence, reflect on their reproductive decisions.

Methods

We recruited transgender and gender-diverse (TGD) people who visited our gender identity clinic and commenced medical treatment in adolescence at least 9 years ago. We collected data through an online survey.

Results

The cohort consisted of 89 participants (66 TGD people assigned female at birth (AFAB) and 23 TGD people assigned male at birth (AMAB) with a mean age of 32.4 years (range 25.5-51.2) at the time of study, and 15.6 years (range 11.5-20.6) at the start of medical treatment. All participants initiated medical treatment before 2014, when laws requiring sterilization for legal gender recognition were still in place, and only 30% of participants reported to have received information about fertility preservation, which none of them pursued. In addition, 96% of participants underwent gonadectomy and thus became permanently infertile, which was troublesome for 27%. With today's knowledge, 44% of TGD people AFAB and 35% of TGD people born AMAB would pursue fertility preservation. The percentage of participants with a (future) desire for children increased from 34% at the start of medical treatment (at adolescent age) to 56% at the time of this study (at adult age), of whom 23% had currently started a family.

Conclusion

It is important to inform transgender adolescents about the effect of medical treatment on fertility and the options for fertility preservation since many may develop a desire for (biological) children when they reach adulthood.

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

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

Fertility preservation choices and decisional regret after gender-affirming surgery in transgender men or gender nonbinary persons

Objective

To investigate the prevalence of decisional regret regarding preoperative fertility preservation choices after gender-affirming surgery or removal of reproductive organs.

Design

Cross-sectional.

Setting

University-based pratice.

Patients

A total of 57 survey respondents identifying as transgender men or gender nonbinary with a history of gender-affirming surgery or removal of reproductive organs between 2014 and 2023 with the University of North Carolina Minimally Invasive Gynecology division.

Intervention

Survey or questionnaire.

Main Outcome Measures

The prevalence and severity of decisional regret regarding preoperative fertility preservation choices were measured with the use of the validated decisional regret scale (DRS) (scored 0-100). Secondary outcomes included patient-reported barriers to pursuing reproductive endocrinology and infertility consultation and fertility preservation treatment.

Results

The survey response rate was 50.9% (57/112). "Mild" to "severe" decisional regret was reported by 38.6% (n = 22) of survey respondents, with DRS scores among all respondents ranging from 0-85. Higher median DRS scores were associated with patient-reported inadequacy of preoperative fertility counseling regarding implications of surgery on future fertility or family-building (0 vs. 50) and fertility preservation options (0 vs. 12.5). No desire for future fertility at the time of fertility counseling was the most frequent reason (68.4%) for declining a referral to reproductive endocrinology and infertility for additional fertility preservation discussion.

Conclusions

Decisional regret regarding preoperative fertility preservation choices is experienced among transgender men or gender nonbinary persons after gender-affirming surgery or the removal of reproductive organs. Preoperative, patient-centered fertility counseling and fertility preservation treatments should be provided to reduce the risk of future regret.

Oocyte cryopreservation and reciprocal in vitro fertilization in a transgender man on long term testosterone gender-affirming hormone therapy: a case report

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.

Family Building in Transgender Patients: Modern Strategies with Assisted Reproductive Technology Treatment

Purpose

Transgender and gender diverse (TGD) individuals continue to face adversity, stigma, and inequality, especially in health care. This study aimed to characterize the experience of TGD people and partners of TGD people with regard to fertility treatment.

Methods

All TGD patients presenting to a single academic center between 2013 and 2021 were included. Baseline demographics collected included patient age, body mass index, anti-Mullerian hormone, basal antral follicle count, history of gender-affirming surgery, and/or gender-affirming hormone therapy. Outcomes included total patients who progressed to treatment, cycle type(s), and clinical outcomes.

Results

In total, 82 patients who identified as TGD or had a partner who identified as TGD presented to care seeking fertility treatment. Of the 141 planned cycles, 106 (75.2%) progressed to treatment. Of the 15 in vitro fertilization (IVF) and co-IVF cycles, 12 achieved live birth. Of the 76 intrauterine inseminations 7 patients were discharged with ongoing pregnancies and one achieved live birth.

Conclusion

These findings reaffirm that TGD individuals utilize the entire array of fertility services. With recent advances in access to care and modern medicine, assisted reproductive technology treatment has the power to support TGD patients in building contemporary family structures.

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

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

Fertility treatment outcomes in transgender men with a history of testosterone therapy

Objective

To evaluate fertility treatment outcomes among transgender (TG) men with a history of gender-affirming hormone therapy with exogenous testosterone.

Design

Descriptive, retrospective cohort study.

Patients

Transgender men with a history of gender-affirming hormone therapy with exogenous testosterone underwent fertility treatments, including embryo cryopreservation, in vitro fertilization (IVF), co-IVF, oocyte cryopreservation, and intrauterine insemination (IUI), between 2013 and 2021.

Intervention

Gender-affirming hormone therapy with testosterone.

Main Outcome Measures

Live births (LBs), number of frozen embryos, and number of frozen oocytes. Other outcome measures included total gonadotropin used, peak estradiol levels, oocytes retrieved, oocyte maturity rate, fertilization rate, and embryo grade.

Results

A total of 77 TG men self-presented or were referred to care at a single academic fertility center, of which 46 (59.7%) TG men underwent fertility preservation and/or family-building counseling, with 16 (20.8%) patients proceeding to fertility treatment. Of those patients who underwent treatment, 11 (68.8%) had a history of gender-affirming hormone therapy with exogenous testosterone use. Cohort 1 included IVF (n = 1), co-IVF (n = 1), embryo cryopreservation (n = 2), cohort 2 included oocyte cryopreservation (n = 4), and cohort 3 included IUI (n = 3). In cohort 1, both the patients who underwent IVF and the patients who underwent co-IVF achieved LBs. All embryo cryopreservation cycles froze three or more embryos. In cohort 2, the average number of frozen mature oocytes was 19.3 ± 16.2 (range 6-43). All patients who underwent IUI cycles achieved LB.

Conclusion

In this study, no correlation existed between patient age, time on or off gender-affirming hormone therapy with exogenous testosterone, total gonadotropin used, and number of oocytes retrieved. All patients who completed IVF or embryo cryopreservation produced high-quality blastocytes, and this is the first study to show successful IUI cycles in patients with a history of gender-affirming hormone therapy with exogenous testosterone. This study demonstrates that TG men who have used gender-affirming hormone therapy previously can successfully undergo fertility treatments to attain oocyte and embryo cryopreservation, pregnancy, and LBs.

Exploring Hormone Therapy Effects on Reproduction and Health in Transgender Individuals

Transgender individuals often face elevated mental health challenges due to gender dysphoria, but gender-affirming treatments such as surgery and hormone therapy have been linked to significant improvements in mental well-being. The potential influence of time and circadian rhythms on these treatments is prevalent. The intricate interplay between hormones, clock genes, and fertility is profound, acknowledging the complexity of reproductive health in transgender individuals. Furthermore, risks associated with gender-affirming hormonal therapy and potential complications of puberty suppression emphasize the importance of ongoing surveillance for these patients and the need of fertility preservation and family-building options for transgender individuals. This narrative review delves into the intricate landscape of hormone therapy for transgender individuals, shedding light on its impact on bone, cardiovascular, and overall health. It explores how hormone therapy affects bone maintenance and cardiovascular risk factors, outlining the complex interplay of testosterone and estrogen. It also underscores the necessity for further research, especially regarding the long-term effects of transgender hormones. This project emphasizes the critical role of healthcare providers, particularly obstetricians and gynecologists, in providing affirming care, calling for comprehensive understanding and integration of transgender treatments. This review will contribute to a better understanding of the impact of hormone therapy on reproductive health and overall well-being in transgender individuals. It will provide valuable insights for healthcare providers, policymakers, and transgender individuals themselves, informing decision-making regarding hormone therapy and fertility preservation options. Additionally, by identifying research gaps, this review will guide future studies to address the evolving healthcare needs of transgender individuals. This project represents a critical step toward addressing the complex healthcare needs of this population. By synthesizing existing knowledge and highlighting areas for further investigation, this review aims to improve the quality of care and support provided to transgender individuals, ultimately enhancing their reproductive health and overall well-being.

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

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

[Transition, fertility and options for preservation of fertility]

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

Gender-affirming pharmacotherapy and additional health considerations: A contemporary review

BACKGROUND

Transgender and gender-diverse (TGD) individuals in the United States face health care disparities compounded with discrimination and limited access to necessary medical services. Gender-affirming interventions have been shown to mitigate gender dysphoria and psychiatric comorbidities, yet United States legislation limiting such interventions has increased. As medication experts, pharmacists can facilitate access to care and appropriate use of gender-affirming hormone therapy (GAHT) and educate other health care providers on best practices for caring for TGD individuals in a variety of settings.

OBJECTIVES

To provide pharmacists with a contemporary review of GAHT and associated medication-related concerns.

METHODS

We searched PubMed for articles published until December 2022. MeSH terms such as transgender, transsexual, gender diverse, gender variant, or gender nonconforming in combination with phrases like gender-affirming care, treatment, pharmacotherapy, or hormone therapy were used to capture desired articles.

RESULTS

Feminizing hormone therapy (FHT), such as estrogen and antiandrogen agents, increases female secondary sex characteristics while suppressing male secondary sex characteristics. Masculinizing hormone therapy (MHT) achieves male secondary sex characteristics and minimizes female secondary sex characteristics using testosterone. For both FHT and MHT, the choice of therapy and formulation ultimately involves the patient's treatment goals, preferences, and tolerability. GAHT has additional health considerations pertaining to renal drug dosing, fertility, cardiovascular, and cancer risks. Pharmacists may provide crucial guidance and education to both patients and health care providers regarding risks associated with GAHT.

CONCLUSION

Many pharmacists feel unprepared to help provide, manage, and optimize GAHT. For many TGD individuals, GAHT is medically necessary and a life-saving treatment. Therefore, pharmacists should be provided tools to close knowledge gaps and improve their ability to care for these patients. By offering a thorough updated overview of GAHT, pharmacists can gain confidence to provide appropriate care for this increasingly visible population.

In vitro fertilization outcomes in a mouse model of gender-affirming hormone therapy in transmasculine youth

OBJECTIVE

To investigate in vitro fertilization (IVF) outcomes in an adolescent transmasculine mouse model mimicking gender-affirming hormone therapy in prepubertal youth, both on testosterone (T) and after T washout.

DESIGN

Experimental laboratory study using a validated mouse model.

SETTING

University-based basic science research laboratory.

ANIMAL(S)

A total of 80 prepubertal 26-day-old C57BL/6N female mice were used in this study.

INTERVENTION(S)

Animals (n = 10/group) were implanted subcutaneously with gonadotropin-releasing hormone agonist at 3.6 mg or received sham surgery. After 21 days, they were implanted with silastic tubing containing either T 10 mg or placebo for 6 weeks. After 6 weeks, a group of animals were superovulated for immediate IVF, and another group had the implant removed and went through superovulation for IVF after 2 weeks (washout IVF). The total number of oocytes yielded, oocyte maturity rate, fertilization rate, and numbers of 2-cell embryos, 4-8-cell embryos, morula, blastocysts, and hatching blastocysts were recorded.

RESULT(S)

Testosterone treatment negatively impacted IVF outcomes in animals stimulated when receiving T, but not after T washout. Pretreatment with gonadotropin-releasing hormone agonist did not affect IVF outcomes.

CONCLUSION(S)

Although current T had a negative impact on IVF outcomes compared with controls, animals were still able to produce viable oocytes for fertilization and develop into blastocysts. Future efforts to study the impact of long-term T exposure on oocyte quality, especially aneuploidy rates, pregnancy outcomes, and live birth rates, are necessary.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Fertility preservation options for transgender and nonbinary individuals

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.

Desire for genetically related children among transgender and gender-diverse patients seeking gender-affirming hormones

Objective

To assess predictors of desire for genetically related children among a national cohort of reproductive-age transgender and gender-diverse patients aged 18 to 44 years initiating gender-affirming hormone therapy for the first time.

Design

Cross-sectional study.

Setting

National telehealth clinic.

Patients

A cohort of patients from 33 US states initiating gender-affirming hormone therapy. A total of 10,270 unique transgender and gender-diverse patients-aged 18 to 44 years (median age 24 years), with no prior use of gender-affirming hormone therapy-completed clinical intake forms between September 1, 2020, and January 1, 2022.

Interventions

Patient sex assigned at birth, insurance status, age, and geographic location.

Main Outcome Measures

Self-reported desire for children using own genetic material.

Results

Transgender and gender-diverse patients seeking gender-affirming medical treatments who are open to having genetically related children are an important population to identify and appropriately counsel. Over one quarter of the study population reported being interested in or unsure about having genetically related children, with 17.8% reporting yes and 8.4% unsure. Male-sex-assigned-at-birth patients had 1.37 (95% confidence interval: 1.25, 1.41) times higher odds of being open to having genetically related children compared with female-sex-assigned-at-birth patients. Those with private insurance had 1.13 (95% confidence interval: 1.02, 1.37) times higher odds of being open to having genetically related children compared with those without insurance.

Conclusions

These findings represent the largest source of self-reported data on the desire for genetically related children among reproductive-age adult transgender and gender-diverse patients seeking gender-affirming hormones. Guidelines recommend that providers offer fertility-related counseling. These results indicate that transgender and gender-diverse patients, particularly male-sex-assigned-at-birth individuals and patients with private insurance, could benefit from counseling regarding the impacts of gender-affirming hormone therapy and gender-affirming surgeries on fertility.

Reproductive endocrinologist and infertility specialists' knowledge, skills, behaviors, and attitudes regarding the care for transgender and gender-diverse individuals

Objective

To investigate associations between reproductive endocrinology and infertility (REI) providers' prior training and current knowledge, skills, attitudes, and behaviors regarding fertility preservation and family building for transgender and gender-diverse (T/GD) patients.

Design

The survey was distributed to members of the Society for Reproductive Endocrinology and Infertility, the REI-physician-focused professional body within the American Society for Reproductive Medicine, with additional participants recruited through snowball sampling.

Results

Participants (n = 206) reported on training in T/GD care; 51% endorsed prior training. Most participants (93%) believed T/GD individuals were as fit for parenthood as cisgender individuals. Prior training was associated with an increased likelihood of offering T/GD health resources and more frequent consultations with specialist colleagues.Common barriers to providing care indicated by respondents included cost, delays in gender-affirming care, and lack of knowledge of the potential impact of hormonal interventions. Common facilitators included education and training, prior experience, and affordability of services.

Conclusions

Most REI providers believed T/GD individuals are fit for parenthood and agreed that prior training facilitates care for T/GD patients. The lack of provider knowledge emerged as a barrier to care. Although training helped facilitate some components of care, systemic barriers such as the cost and variability of patient population characteristics/experiences are important considerations when serving T/GD individuals.

Oocyte Cryopreservation for Medical and Planned Indications: A Practical Guide and Overview

Oocyte cryopreservation (OC) is the process in which ovarian follicles are stimulated, the follicular fluid is retrieved, and mature oocytes are isolated and vitrified. Since the first successful pregnancy utilizing previously cryopreserved oocytes in 1986, OC has become increasingly utilized as an option for future biologic children in patients facing gonadotoxic therapies, such as for the treatment of cancer. Planned OC, also termed elective OC, is growing in popularity as a means to circumvent age-related fertility decline. In this narrative review, we describe both medically indicated and planned OC, focusing on the physiology of ovarian follicular loss, OC technique and risks, timing of when OC should be performed, associated financial considerations, and outcomes.

Informed consent in assisted reproduction: an Ethics Committee opinion

Informed consent is a process in which the patient is supported in developing an understanding of medical options (including risks, benefits, and alternatives) and coming to a voluntary and autonomous decision.

Fertility preservation in pediatric healthcare: a review

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

The barriers and needs of transgender men in pregnancy and childbirth: A qualitative interview study

OBJECTIVE

Transgender and gender diverse individuals are individuals whose gender identity differs from their sex assigned at birth. The discordance between gender identity and sex assignment may cause significant psychological distress: gender dysphoria. Transgender individuals may choose to undergo gender-affirming hormone treatment or surgery, but some decide to (temporarily) refrain from surgery and gender affirming hormone treatment and hence retain the possibility to become pregnant. Pregnancy may enhance feelings of gender dysphoria and isolation. To improve perinatal care for transgender individuals and their health care providers, we conducted interviews to explore the needs and barriers of transgender men in family planning, pregnancy, childbirth, puerperium and perinatal care.

DESIGN

In this qualitative study five in-depth semi-structured interviews were conducted with Dutch transgender men who had given birth while identifying on the transmasculine spectrum. The interviews were conducted online through a video remote-conferencing software program (n=4) or live (n=1). Interviews were transcribed verbatim. An inductive approach was used to find patterns and collect data from the participants' narratives and constant comparative method was adapted in analysing the interviews.

MEASUREMENTS AND FINDINGS

The experiences of transgender men regarding the preconception period, pregnancy and puerperium and with perinatal care varied widely. Though all participants expressed overall positive experiences, their narratives emphasized they had to overcome substantial hurdles pursuing pregnancy. For instance the necessity to prioritise becoming pregnant over gender transitioning, lack of support by healthcare providers and increased gender dysphoria and isolation during pregnancy KEY CONCLUSIONS: Since pregnancy in transgender men enhances feelings of gender dysphoria, transgender men comprise a vulnerable group in perinatal care. Health care providers are perceived as feeling unaccustomed for the care of transgender patients, as they are perceived to often lack the right tools and knowledge to provide adequate care. Our findings help strengthen the foundation of insight in the needs and hurdles of transgender men pursuing pregnancy and therefore may guide health care providers to provide equitable perinatal care, and emphasize the necessity of patient-centred gender-inclusive perinatal care. A guideline including the option for consultation of an expertise center is advised to facilitate patient-centered gender-inclusive perinatal care.

Public opinions regarding infertility treatment insurance coverage among marginalized patient populations

PURPOSE

To assess public support for insurance coverage of infertility treatment among marginalized patient groups.

METHODS

A cross-sectional, web survey-based study using a national sample of 1226 US adults. Participants responded to questions measuring their beliefs and attitudes towards support for infertility treatment insurance coverage among specific patient populations. We then evaluated the opinions of only the participants who supported infertility treatment insurance coverage for patients meeting the standard definition of infertility. Associations between demographic data of participants and support for infertility treatment insurance coverage among these marginalized groups were queried.

RESULTS

Of the total responses, 61.9% of the respondents generally supported insurance coverage for infertility. Of the total responses, 54.5% did not support any insurance coverage for lesbian, gay, or transgender patients. Of those who generally supported the insurance coverage for infertility, 53.0% supported coverage for gay patients requiring infertility services, 54.6% supported coverage for lesbian patients, and 42.5% supported coverage for transgender patients. Of the total responses, 47.6% did not support insurance for green card holders, undocumented immigrants, or refugees. Of those who supported the insurance coverage for infertility in general, 63.6% supported insurance coverage for patients with green cards, 29.8% for refugees, and 20.7% for undocumented patients. For disability and genetic conditions, 39.5% did not support coverage for any groups. Of those who support the insurance coverage for infertility in general, there was most support for patients with physical disabilities (60.2%) followed by genetic disease (47.9%), then mental disabilities (31.4%).

CONCLUSION

Even among those who support insurance coverage for infertility in general, approximately less than half of them supported these same treatments for marginalized groups, including the diverse sexuality and gender (DSG), immigrant, and disabled populations. Increased education and awareness of infertility is needed among the general population to garner acceptance of infertility as a disease and support insurance coverage of infertility treatment for all persons.

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

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

A mouse model mimicking gender-affirming treatment with pubertal suppression followed by testosterone in transmasculine youth

STUDY QUESTION

Can mice serve as a translational model to examine the reproductive consequences of pubertal suppression with GnRH agonist (GnRHa) followed by testosterone (T) administration, a typical therapy in peripubertal transmasculine youth?

SUMMARY ANSWER

An implanted depot with 3.6 mg of GnRHa followed by T enanthate at 0.45 mg weekly can be used in peripubertal female mice for investigating the impact of gender-affirming hormone therapy in transmasculine youth.

WHAT IS KNOWN ALREADY

There is limited knowledge available in transgender medicine to provide evidence-based fertility care, with the current guidelines being based on the assumption of fertility loss. We recently successfully developed a mouse model to investigate the reproductive consequences of T therapy given to transgender men. On the other hand, to our knowledge, there is no mouse model to assess the reproductive outcomes in peripubertal transmasculine youth.

STUDY DESIGN, SIZE, DURATION

A total of 80 C57BL/6N female mice were used in this study, with n = 7 mice in each experimental group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We first assessed the effectiveness of GnRHa in arresting pubertal development in the female mice. In this experiment, 26-day-old female mice were subcutaneously implanted with a GnRHa (3.6 mg) depot. Controls underwent a sham surgery. Animals were euthanized at 3, 9, 21 and 28 days after the day of surgery. In the second experiment, we induced a transmasculine youth mouse model. C57BL/6N female mice were subcutaneously implanted with a 3.6 mg GnRHa depot on postnatal day 26 for 21 days and this was followed by weekly injections of 0.45 mg T enanthate for 6 weeks. The control for the GnRH treatment was sham surgery and the control for T treatment was sesame oil vehicle injections. Animals were sacrificed 0.5 weeks after the last injection. The data collected included the day of the vaginal opening and first estrus, daily vaginal cytology, weekly and terminal reproductive hormones levels, body/organ weights, ovarian follicular distribution and corpora lutea (CL) counts.

MAIN RESULTS AND THE ROLE OF CHANCE

GnRHa implanted animals remained in persistent diestrus and had reduced levels of FSH (P = 0.0013), LH (P = 0.0082) and estradiol (P = 0.0155), decreased uterine (P < 0.0001) and ovarian weights (P = 0.0002), and a lack of CL at 21 days after GnRHa implantation. T-only and GnRHa+T-treated animals were acyclic throughout the treatment period, had sustained elevated levels of T, suppressed LH levels (P < 0.0001), and an absence of CL compared to controls (P < 0.0001). Paired ovarian weights were reduced in the T-only and GnRHa+T groups compared with the control and GnRHa-only groups.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

Although it is an appropriate tool to provide relevant findings, precaution is needed to extrapolate mouse model results to mirror human reproductive physiology.

WIDER IMPLICATIONS OF THE FINDINGS

To our knowledge, this study describes the first mouse model mimicking gender-affirming hormone therapy in peripubertal transmasculine youth. This model provides a tool for researchers studying the effects of GnRHa-T therapy on other aspects of reproduction, other organ systems and transgenerational effects. The model is supported by GnRHa suppressing puberty and maintaining acyclicity during T treatment, lower LH levels and absence of CL. The results also suggest GnRHa+T therapy in peripubertal female mice does not affect ovarian reserve, since the number of primordial follicles was not affected by treatment.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Michigan Institute for Clinical and Health Research grants KL2 TR 002241 and UL1 TR 002240 (C.D.C.); National Institutes of Health grants F30-HD100163 and T32-HD079342 (H.M.K.); University of Michigan Office of Research funding U058227 (A.S.); American Society for Reproductive Medicine/Society for Reproductive Endocrinology and Infertility grant (M.B.M.); and National Institutes of Health R01-HD098233 (M.B.M.). The University of Virginia Center for Research in Reproduction Ligand Assay and Analysis Core Facility was supported by the Eunice Kennedy Shriver NICHD/NIH grants P50-HD028934 and R24-HD102061. The authors declare that they have no competing interests.

Family Planning and Fertility Counseling Perspectives of Gender Diverse Adults and Youth Pursuing or Receiving Gender Affirming Hormone Therapy

OBJECTIVE

To describe family planning and fertility counseling perspectives of reproductive-age gender diverse adults and youth pursuing gender affirming hormone therapy.

MATERIALS AND METHODS

This was a cross sectional survey study of gender diverse adults and youth pursuing or receiving gender affirming hormone therapy. The primary outcomes of interest were parental desire and priorities for fertility preservation.

RESULTS

Fifty-seven individuals (46 adults and 11 youths) completed the survey; 51% were transgender women, 35% were transgender men, and 14% identified as non-binary. 32 participants expressed interest in (n = 15, 26%) or uncertainty about (n = 18, 32%) future parenthood. 48% of participants had considered gamete cryopreservation, but only 7% each previously completed or planned to pursue this fertility option; 67% cited cost as a barrier. Participants with interest in or uncertainty about future parenthood were more likely to consider cryopreservation (P <.001) or stopping hormones for fertility preservation (P <.001). 58% of respondents reported discussing fertility preservation with a health care provider with lower rates among youth participants (P = .017). From a family planning perspective, 58% of respondents described counseling as adequate; 23% described it as inadequate and 19% reported not receiving any counseling. Participants who endorsed strong or uncertain parental desire were more likely to report inadequate counseling (P = .016).

CONCLUSION

Gender diverse individuals interested in or undecided about future parenthood were more likely to consider cryopreservation and report inadequate family planning counseling. Therefore, current counseling practices may be insufficient and referral to a fertility specialist should be considered.

[Fertility preservation for transmen]

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

Préservation de la fertilité chez les personnes transgenres

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

[Fertility preservation and access to medically assisted reproduction for Trans people: Guidelines from French Professional Association for Transgender Health]

Many health care professionals are dealing with the issue of transgender people in their medical practice. In the field of reproduction, Trans people can benefit from fertility preservation before the introduction of hormonal treatment or surgery altering their fertility. This article, which is the result of a collaborative work of several reproductive professionals involved in the health of Trans people, provides an overview of the possibilities of fertility preservation and medically assisted reproduction techniques in France for Trans people.

Fertility Preservation and Reproductive Potential in Transgender and Gender Fluid Population

The gender diverse and transgender community is a minor patient group that is encountered with increasing frequency in the clinical setting, attributed to the improved awareness and access to medical facilities. Partial impairment to permanent elimination of fertility potential and outcomes depending on the treatment modality usually is a result of gender-affirming therapy, which includes both hormone therapy and surgical intervention. Although seldom conducted in the clinical field, transgender patients should be counseled on their fertility preservation options prior to medical and surgical gender transition. There is relatively limited data and clinical information regarding fertility preservation for transgender individuals. Current treatment regimens are based on protocols from fertility preservation after oncological treatments. Major barriers for the transgender population exist due to the lack of information provided and clinical narrative that is not familiar to the physician or health care provider, although there are various options for fertility preservation. A deeper understanding of this clinical agenda and the mandatory processes will ultimately result in a much more comprehensive and specific care for transgender individuals who are in great need for fertility counseling or treatment options that concern fertility preservation. In this review, current clinical approaches will be summarized and fertility preservation options along with ongoing and future clinical trials in fertility preservation for transgender individuals will be thoroughly reviewed.

Fertility preservation in transgender men and the need for uniform, comprehensive counseling

Objective

To review the literature to assess best practices for counseling transgender men who desire gender-affirming surgery on fertility preservation options.

Design

A scoping review of articles published through July 2021.

Setting

None.

Patient(s)

Articles published in Cochrane, Web of Science, PubMed, Science Direct, SCOPUS, and Psychinfo.

Intervention(s)

None.

Main Outcome Measure(s)

Papers discussing transgender men, fertility preservation (FP), and FP counseling.

Result(s)

The primary search yielded 1,067 publications. After assessing eligibility and evaluating with a quality assessment tool, 25 articles remained, including 8 reviews, 5 surveys, 4 consensus studies, 3 retrospective studies, 3 committee opinions, and 2 guidelines. Publications highlighted the importance of including the following topics during counseling: (1) FP and family building options; (2) FP outcomes; (3) effects of testosterone therapy on fertility; (4) contraception counseling; (5) attitudes toward family building; (6) consequences of transgender parenting; and (7) barriers to success.

Conclusion(s)

Currently, there is a lack of standardization for comprehensive counseling about FP for transgender men. Standardized approaches can facilitate conversation between physicians and transgender men and ensure patients are making informed decisions regarding pelvic surgery and future family building plans.

Pathways to fatherhood: clinical experiences with assisted reproductive technology in single and coupled intended fathers

Objective

To explore the cycle characteristics and outcomes of single and coupled intended fathers (SCIFs) using assisted reproductive technology.

Design

Cross-sectional study.

Setting

Multicenter, fertility practices from 2016 to 2020.

Patients

In this study, cycles among SCIFs with access to fertility coverage from 2016 to 2020 were included.

Interventions

None.

Main Outcome Measures

Our primary outcome was live birth rate. The secondary outcomes included the number of embryos transferred, miscarriage rate, and incidence of multifetal birth.

Results

Five single and 39 coupled intended fathers completed an in vitro fertilization cycle with a majority using egg donation and an agency-based gestational carrier (69.7%, 83/119). In most couples, both partners wanted to serve as the sperm source (64.4%, 29/45). The vast majority (97.7%, 43/44) also used preimplantation genetic testing for aneuploidy. Among the embryo transfer (ET) cycles (n = 27), most consisted of a single euploid ET (74.07%, 20/27), whereas the remaining consisted of a double euploid ET (25.92%, 7/27). The SCIFs had high rates of success, with a live birth rate of 85.19% (23/27). A mean of 1.26 ± 0.44 embryos were transferred, with a majority resulting in singleton birth (70.37%, 19/27).

Conclusions

Our study of SCIFs using assisted reproductive technology in the United States demonstrates that this population shares similar preferences for sperm source and the use of preimplantation genetic testing. Clinical outcomes suggest that this population is successful at achieving a live birth when using egg donation and a gestational carrier.

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

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

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

Background

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

Aims

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

Methods

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

Results

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

Discussion

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

Social media engagement with transgender fertility content

Objective

Design

Setting

Patient(s)

Intervention(s)

Main Outcome Measure(s)

Result(s)

Conclusion(s)

Reproductive potential and fertility preservation in transgender and nonbinary individuals

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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