Fertility Desires of Adolescent Females: Decreased Desire for Children in Those Identifying as Transgender/Gender Diverse and in Depressed Adolescents

Reproductive and Fertility Knowledge and Attitudes Among Transgender and Gender-Expansive Youth: A Replication and Extension

Purpose

This study sought to replicate and expand a previous pilot investigation of reproductive knowledge, attitudes toward fertility and parenthood, and sources of information on these topics among transgender and gender-expansive (TGE) youth.

Methods

The Yale Pediatric Gender Program (YPGP) Reproductive Knowledge and Experiences Survey (YPGP-RKES) was administered to 70 TGE adolescents receiving care at an interdisciplinary clinic providing gender-affirming health care at an academic medical center. Data gathered included sources of information on reproduction and fertility, concerns about future parenthood and reproduction, and interest in different types of parenthood.

Results

Over a third (39.1%) of participants reported it was important to them to have a child one day, while only a small proportion (23.2%) reported an interest in biological parenthood. A plurality of participants (37.3%) reported at least one concern about future fertility. The number of reproductive concerns did not differ by age or treatment (puberty blockers or gender-affirming hormones vs. no treatment) status. With respect to needs for more information and sources of information, most (56.5%) participants received information about fertility issues before this study, with the most cited source of information being online research.

Conclusions

The current study replicated and extended previous findings on the reproductive attitudes and knowledge of TGE adolescents. Understanding the informational needs and priorities of adolescent TGE patients presenting for medical treatment will allow providers to give more robust patient education. This will, in turn, facilitate patients' ability to provide fully informed consent for treatment that aligns with their fertility and reproductive priorities and goals.

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.

Assessing Fertility Intentions in Patients Presenting for Gender-Affirming Surgery

Purpose: For some transgender and gender-diverse (TGD) individuals, gender-affirming surgery may represent the last opportunity to engage in gamete banking (GB) and other forms of fertility preservation (FP). Previous research has assessed fertility intentions among TGD people initiating hormone therapy. The objective of this study was to describe the fertility intentions of patients seeking gender-affirming surgery. Methods: A retrospective chart review was conducted for 233 patients seeking chest or genital surgery between 2017 and 2019. Data abstracted included interest in having children (biological or non-biological) and GB, and barriers to FP. Associations between fertility intentions, sex assigned at birth, and surgical procedure sought were assessed. Results: Of the 233 records reviewed, 162 (70%) documented information about fertility intentions for patients without a history of sterilizing surgery. At initial consultation, 94% were receiving hormone therapy. Among the 60 patients seeking genital surgery, 30% expressed interest in GB and 38% were not interested in biological children. Among the 102 patients seeking chest surgery, 11% expressed interest in GB and 47% were not interested in biological children. Patients assigned male at birth were more likely to have already completed GB (p < 0.001). Among the patients interested in FP, 41% reported barriers to access. Conclusion: Many TGD people in our study expressed no interest in biological parenthood; however, 30% of patients seeking genital surgery expressed interest in GB. This suggests that some who defer FP when starting hormones may wish to pursue it later in life. Ongoing assessment of fertility intentions and reducing barriers to FP are integral to caring for TGD people.

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.