Clinicopathologic features and proposed grossing protocol of orchiectomy specimens performed for gender affirmation surgery

[Fertility preservation in persons with gender incongruence and male-assigned sex at birth]

According to current guidelines, patients with gender incongruence seeking treatment must receive appropriate education and counselling from healthcare professionals on the various options for fertility preservation. Gender-affirming hormonal treatment leads in persons assigned male at birth to a reduction of LH, FSH, and testosterone, which is associated with a regression of spermatogenesis (up to complete loss) and subsequent testicular atrophy. Individuals starting gender-affirming hormonal treatment after having experienced male puberty may provide an ejaculate sample for sperm cryopreservation. In cases where no sperm is detected in the ejaculate due to gender-affirming hormonal treatment, or if the sampling of ejaculate is no longer possible or causes excessive psychological distress, (microsurgical) testicular sperm extraction [(m)TESE] should be offered. Electroejaculation under anaesthesia is rarely effective, as hormonal treatment impairs spermatogenesis. Similarly, microsurgical epididymal sperm aspiration (MESA) is not typically effective for the same reason. If adolescents with gender incongruence undergo puberty blockade and/or gender-affirming hormonal treatment at an early stage of puberty (possible from Tanner stage 2), this prevents the maturation of spermatogonial stem cells into mature sperm. Puberty blockade with GnRH reduces the secretion of LH and FSH by the pituitary gland, which, in turn, suppresses the production of testosterone in the Leydig cells and the stimulation of spermatogenesis in the testicles. In such cases, the cryopreservation of spermatogonial stem cells is possible, similar to how it is offered in some countries for peri-pubertal patients prior to necessary germ cell-toxic treatments. In Germany, there is a relevant network (Androprotect), which was founded in Münster in 2012. Via Androprotect, this procedure is also offered for adolescent individuals with gender incongruence. This approach is considered experimental as no established treatment exists for the refertilisation of affected adults at a later stage, although several procedures for in-vitro sperm maturation and tissue transplantation are under development. The care of patients with gender incongruence should include individual counselling provided by experienced professionals in an interdisciplinary treatment team. Individual treatment approaches should be offered to facilitate shared decision-making (based on informed consent) to ensure that each individual can make an informed and appropriate decision regarding fertility preservation.

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

BACKGROUND

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

OBJECTIVE AND RATIONALE

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

SEARCH METHODS

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

OUTCOMES

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

WIDER IMPLICATIONS

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

Partial rejuvenation of the spermatogonial stem cell niche after gender-affirming hormone therapy in trans women

Although the impact of gender-affirming hormone therapy (GAHT) on spermatogenesis in trans women has already been studied, data on its precise effects on the testicular environment is poor. Therefore, this study aimed to characterize, through histological and transcriptomic analysis, the spermatogonial stem cell niche of 106 trans women who underwent standardized GAHT, comprising estrogens and cyproterone acetate. A partial dedifferentiation of Sertoli cells was observed, marked by the co-expression of androgen receptor and anti-Müllerian hormone which mirrors the situation in peripubertal boys. The Leydig cells also exhibited a distribution analogous to peripubertal tissue, accompanied by a reduced insulin-like factor 3 expression. Although most peritubular myoid cells expressed alpha-smooth muscle actin 2, the expression pattern was disturbed. Besides this, fibrosis was particularly evident in the tubular wall and the lumen was collapsing in most participants. A spermatogenic arrest was also observed in all participants. The transcriptomic profile of transgender tissue confirmed a loss of mature characteristics - a partial rejuvenation - of the spermatogonial stem cell niche and, in addition, detected inflammation processes occurring in the samples. The present study shows that GAHT changes the spermatogonial stem cell niche by partially rejuvenating the somatic cells and inducing fibrotic processes. These findings are important to further understand how estrogens and testosterone suppression affect the testis environment, and in the case of orchidectomized testes as medical waste material, their potential use in research.

Diagnostic incidence and pitfalls of rete testis hyperplasia and hyaline globules in a multi-institutional study of 348 testicular germ cell tumors

OBJECTIVES

The concept of rete hyperplasia with hyaline globules simulating testicular yolk sac tumor was first reported in a mostly retrospective review over 30 years ago. Nonetheless, we continue to encounter examples where this scenario resulted in misdiagnosis. Herein, we sought to investigate the incidence of rete hyperplasia/hyaline globules in germ cell tumors and their associated subtypes and hypothesize an etiology.

METHODS

A consecutive series of 348 germ cell tumor orchiectomies was evaluated for the presence of rete hyperplasia and hyaline globules, with clinicopathologic features recorded.

RESULTS

The incidence of rete hyperplasia and/or hyaline globules in our cohort was 30%, with 56% of specimens with rete hyperplasia containing concomitant hyaline globules. Hyaline globules were more often identified in specimens with nonfocal rete hyperplasia (78%) vs focal rete hyperplasia (22%). Absence of a yolk sac tumor component was seen in over half (61%) of orchiectomies with concurrent rete hyperplasia/hyaline globules (n = 105), inclusive of tumors with "pure" subtypes (ie, pure seminoma, pure teratoma, or pure embryonal carcinoma). Of these 105 specimens, rete invasion was seen in only 48%; notably, Paneth cell-like metaplasia was identified in efferent ductules/epididymis in 13%.

CONCLUSIONS

Rete hyperplasia and hyaline globules are not uncommon findings in the setting of germ cell tumors (including occurrences in various pure/mixed germ cell tumors) and can show striking overlap with yolk sac tumor. We hypothesize that these histologic pitfalls evolve secondary to testicular obstruction by the tumor mass. Recognition of and distinguishing this morphologic mimicry is fundamental to guide appropriate clinical management.

Incidental testicular germ cell tumor in a transgender woman: A case report

Testicular cancer found incidentally during gender-affirming orchiectomy is infrequently reported in the literature. This report details a 27-year-old transgender woman whose testicular cancer was discovered incidentally upon routine histopathologic examination of the orchiectomy specimen. The patient did not present with any clinical signs of malignancy. There was no evidence of metastases after further workup and the patient was able to resume hormone therapy after surgery. Transgender individuals must be screened according to their natal anatomy and even in absence of clinical signs excised tissue should be examined for possible malignancy.

Spectrum of Histologic Findings in Orchiectomy Specimens of Patients Seeking Male to Female Physical Adaptation

Context. Hormonal therapy followed by orchiectomy is of the standard of care in management of gender identity disorder in patients seeking male to female transition. The orchiectomy specimens from these patients are routinely subjected to histopathologic evaluation. We discuss the spectrum of histopathologic findings, incidental findings, and cost analysis of processing these specimens. Design. Orchiectomy specimens from patients seeking male to female transition received at our institution from January 2019 to June 2021 were included in the study. Data including patient age, history of hormonal therapy, testicular weight, histopathologic findings, number of tissue sections, and processing cost were collected. Results. A total of 79 specimens were identified. Mean patient age was 36.7 ± 14.5 years. Mean testicular weight was 28.0 ± 8.3 g (right) and 27.8 ± 9.1 g (left). Histologic evaluation showed diminished or absent spermatogenesis in 100% and fibrosis of seminiferous tubules in 96% of specimens. Benign, incidental findings, none of which altered patient management were present in 6 specimens (8%). For most specimens, 3 sections per testis were submitted. This resulted in a mean of 5.8 ± 1.1 tissue sections submitted per specimen. Conclusions. Orchiectomy specimens from patients with gender dysphoria always demonstrate hormone-therapy effects albeit with varying degree. The chances of discovering any incidental finding of clinical significance are negligible. Diligent gross inspection and minimal tissue sampling with additional sampling reserved for gross abnormalities can adequately document the histologic findings in a cost-effective manner.