Fertility preservation options for transgender and gender-nonconforming individuals

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.

[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.

Puberty Suppression Followed by Testosterone Therapy Does Not Impair Reproductive Potential in Female Mice

More adolescents are coming out as transgender each year and are put on puberty blockers to suppress natal puberty, which is then followed by cross-hormone treatment to achieve puberty of the desired gender. Studies to examine the effects of puberty suppression and virilizing therapy on future reproductive potential among transgender males are lacking. This study used a translational murine in vitro fertilization model to examine the effects of female puberty suppression with depot leuprolide acetate (LA), followed by virilizing therapy with testosterone cypionate (T), on embryologic and pregnancy outcomes. LA effectively inhibited puberty when mice were treated beginning at 3 weeks of age. LA treatment was associated with higher mouse weight but lower ovarian weight. LA-treated mice ovulated developmentally competent eggs in response to gonadotropin administration, albeit at a higher dose than controls. Ovaries from mice treated with LA and T produced oocytes that had morphologically normal meiotic spindles after in vitro maturation and responded to gonadotropin stimulation. Eggs from mice treated with LA and T were fertilizable and produced developmentally competent embryos that led to births of fertile pups. These results suggest that fertility may not be impaired after puberty suppression and cross-hormone therapy for transgender males.

Success in Accessing Fertility Preservation Appointments for Egg-Producing Transgender and Gender-Diverse Patients: A Mystery Caller Study

Purpose: This study aimed to evaluate access to fertility preservation appointments for egg-producing transgender and gender-diverse patients. Methods: Fertility clinics nationwide were identified through the 2018 National Assisted Reproductive Technology Surveillance System dataset of the Centers for Disease Control and Prevention. Using a mystery caller approach with a standardized, community-developed script, three researchers called 456 clinics between July and December 2020 identifying themselves as a transgender man seeking oocyte cryopreservation. Information was collected regarding access to fertility preservation for the caller. Univariate and multivariable logistic regression analysis were used to compare call outcomes by geographic region and clinic demographics. Results: Of 369 clinics included in the final analysis, 90.2% of clinics offered an initial appointment. A clinic that offered an appointment was four times more likely to be located on the West Coast (95% confidence interval [CI] 1.33-12.7; p = 0.014). Notably, endorsement of prior experience caring for transgender patients was most strongly associated with an appointment being offered (odds ratio = 7.31; 95% CI: 3.44-15.5; p < 0.001). Themes across some calls included a lack of knowledge about transgender identities and care models (e.g., requiring a letter of support) leading to additional steps (e.g., having to explain anatomy or being transferred to another staff member) before accessing an appointment. Conclusion: The majority of clinics offered an initial appointment to a caller identifying as a transgender man seeking oocyte cryopreservation, suggesting access to an initial appointment is not a major barrier.

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.

"Lights and Shades" of Fertility Preservation in Transgender Men Patients: A Clinical and Pathological Review

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.

Decision Support Needs for Transgender and Gender-Diverse Youth and Families: A Patient-Centered Needs Assessment

PURPOSE

Due to the intertwining of medical and social decision-making, new approaches to shared decision-making are likely needed for supporting decisions related to the care of transgender and gender-diverse (TGD) adolescents. Prior to developing decision support interventions for TGD youth, a decision support needs assessment must be completed.

METHODS

Self-identified TGD youth, family members of TGD youth, clinicians caring for this population, and community advocates participated in one of six group level assessments (GLAs). GLA is a structured, participatory qualitative method that engages diverse groups of stakeholders in generating and evaluating ideas on the topic of interest. Upon completion of all GLAs, a survey was developed and distributed to GLA participants inviting them to rank ideas generated during the GLAs.

RESULTS

Six major themes emerged from the GLAs regarding decision support needs, including: improving healthcare provider skills and education, increasing access to support outside the healthcare system, strengthening community and societal support, developing special information resources, supporting youth in leading decision-making about transition, and modifying the healthcare system. In the follow-up survey, improving healthcare provider skills and education was the most commonly chosen top priority.

DISCUSSION

Participants identified decision support needs for TGD youth and their families that were mostly distinct from traditional decision support approaches. Participants' focus on the need to improve healthcare provider skills and education provides an opportunity to couple gender-focused education with shared decision-making skills, an approach that may be more sustainable than tools for specific decisions.

Evidence of Spermatogenesis in the Presence of Hypothalamic Suppression and Low Testosterone in an Adolescent Transgender Female: A Case Report

Objective

To report a novel case of semen cryopreservation after testicular sperm extraction in an adolescent transgender female without cessation of gonadotropin-releasing hormone (GnRH) agonist therapy and feminizing hormone therapy.

Methods

This is a case report of a 16-year-old transgender female using leuprolide acetate for 4 years and estradiol for 3 years requesting semen cryopreservation at the time of gender-affirming orchiectomy. She desired to proceed without cessation of gender affirming hormone therapy. The patient's consent was obtained for written publication.

Results

The patient underwent testicular sperm extraction followed by orchiectomy. The sample was processed and cryopreserved in a 1:1 Test Yolk Buffer. Multiple early and late spermatids were identified as well as spermatagonium in the TESE specimen.

Conclusions

Advanced spermatogenesis may occur in the presence of a GnRH agonist. Cessation of GnRH agonist therapy may not be essential for semen cryopreservation in adolescent transgender females.

[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.

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.

Menstrual considerations for transgender male and gender diverse adolescents who were assigned female at birth

Menstruation is a female normative process. Physiologically, it indicates that the hypothalamic-pituitary-ovarian axis is functioning appropriately, and all the correct female end-organs are intact. Menarche also heralds a girl's arrival into womanhood, which culturally is often celebrated. It is a sign of the possibility of fertility, pregnancy and motherhood. However, menstruation for transgender males, and other gender diverse individuals assigned female at birth, may be anything but celebratory. For these adolescents, menstruation is an indication that one's body is not functioning appropriately and that one does not have the correct organs congruent to their gender identity. Menstruation or the anticipation of menarche for many transgender males is often met with worsening of dysphoria, anxiety, depression and suicidal ideation. Therefore, to meet the physiologic and psychologic needs of transgender males, one needs to be aware of issues that may be present in relation to menstruation and be knowledgeable on how to medically proceed with sensitivity and respect toward one's gender identity. Research on menstruation, both from a physical and psychologic perspective, has been historically based on women and cannot be simply extrapolated to be the same for transgender males. Although there is a paucity of literature on the subject, over the past decade there has begun to be a great interest in the care of transgender individuals. This article focuses on concerns related to menstruation among transgender adolescent males and gender diverse individuals assigned female at birth, including suppression of menses, fertility, contraception, and pregnancy.

Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review

INTRODUCTION

The transmasculine and gender diverse (TMGD) spectrum includes transgender men and non-binary individuals whose sex was assigned female at birth. Many TMGD patients pursue treatment with exogenous testosterone to acquire masculine characteristics. Some may choose to undergo gynecological gender-affirming surgery for total hysterectomy with bilateral salpingectomy and/or bilateral oophorectomy (TH/BSO). The decision to retain or remove the ovaries in the setting of chronic testosterone therapy has implications on reproductive health, oncologic risk, endocrine management, cardiovascular health, bone density and neurocognitive status. However, there is limited evidence on the long-term outcomes from this intervention.

OBJECTIVE

Here we review health-related outcomes of oophorectomy in TMGD population treated with chronic testosterone therapy in order to guide clinicians and patients in the decision to retain or remove their ovaries.

METHOD

We conducted a systematic literature review following PRISMA guidelines. MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library databases were searched for peer-reviewed studies published prior to October 26, 2021 that: (i) included transgender men/TMGD individuals in the study populations; (ii) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (iii) specifically discussed ovaries, hysterectomy, oophorectomy, ovariectomy, or gonadectomy.

RESULTS

We identified 469 studies, of which 39 met our inclusion criteria for this review. Three studies discussed fertility outcomes, 11 assessed histopathological changes to the ovaries, 6 discussed ovarian oncological outcomes, 8 addressed endocrine considerations, 3 discussed cardiovascular health outcomes, and 8 discussed bone density. No studies were found that examined surgical outcomes or neurocognitive changes.

CONCLUSION

There is little information to guide TMGD individuals who are considering TH/BSO versus TH/BS with ovarian retention. Our review suggests that there is limited evidence to suggest that fertility preservation is successful after TH/BS with ovarian retention. Current evidence does not support regular reduction in testosterone dosing following oophorectomy. Estradiol levels are likely higher in individuals that choose ovarian retention, but this has not been clearly demonstrated. Although bone mineral density decreases following oophorectomy, data demonstrating an increased fracture risk are lacking. No studies have described the specific impact on neurocognitive function, or changes in operative complications. Further research evaluating long-term health outcomes of oophorectomy for TMGD individuals treated with chronic testosterone therapy is warranted to provide comprehensive, evidence-based healthcare to this patient population. Sahil Kumar, Smita Mukherjee, Cormac O'Dwyer, et al. Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review. Sex Med Rev 2022;XX:XXX-XXX.

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.

"Queer Insights": Considerations and Challenges for Assessing Sex, Gender Identity, and Sexual Orientation in Oncofertility Research

This article addresses issues related to clinical and research approaches to oncofertility for adolescent and young adult (AYA) sexual and gender minority (SGM) cancer patients. Limited attention has been dedicated to understanding the extent to which oncofertility services are appropriately and equitably delivered to AYAs with diverse orientations toward sexual orientation, gender identity, and future family. Unresolved challenges to conducting research with this vulnerable population perpetuate a lack of adequate knowledge about SGM AYA oncofertility needs. Therefore, the purpose of this paper is to inform considerations of sex, gender identity, and sexual orientation for investigations that include SGM AYAs. In order to improve the knowledge base and clinical services for this population, we discuss (1) challenges to sampling this population; (2) categorization and survey logic (e.g., skip patterns) in light of fluid sexual orientation and gender identities; and (3) clinical implications of accurately assessing sex and gender for oncofertility research and practice. We also recommend strategies for producing inclusive and accurate assessments of sexual and gender identity categories in both research and clinical encounters with SGM AYAs. Incorporating "queer insights" into empirical research - that is, positioning queer theory at the center of oncofertility study design - is suggested as a future direction for oncofertility research and practice.

Fertility preservation and fertility treatment in transgender adolescents and adults in a Swedish region, 2013-2018

STUDY QUESTION

In a transgender population referred for fertility consultation, which factors influence the decision to cryopreserve oocytes and sperm?

SUMMARY ANSWER

Previous hormonal treatment, gender affirmation surgery and sexual orientation were associated with the decision to undergo fertility preservation and transgender women underwent fertility preservation more frequently than transgender men.

WHAT IS KNOWN ALREADY

It is well-known internationally that fertility preservation and fertility treatment are increasingly requested by transgender men and women. Factors affecting their decisions as well as treatment differences between transgender women and transgender men have been reported, but many studies have had low participation rates and small sample sizes.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study, conducted during 2013–2018, included 78 transgender women (assigned male at birth and referred for sperm cryopreservation) and 164 transgender men (assigned female at birth referred for oocyte cryopreservation).

PARTICIPANTS/MATERIALS, SETTING, METHODS

In 2013, the previous requirement for sterilization before completion of a legal gender change was removed in Sweden. All fertile-aged transgender men and transgender women referred to a tertiary care centre for consultation concerning fertility preservation, fertility treatment or hysterectomy were identified from administrative systems. Demographic, medical and treatment data were extracted from electronic medical records and from an ART database. Logistic regression was applied to analyse factors affecting the decision to cryopreserve gametes among transgender men and transgender women.

MAIN RESULTS AND THE ROLE OF CHANCE

A majority of transgender men (69.5%) and transgender women (82%), wanted to become parents. Fertility preservation was less frequent in transgender men than in transgender women (26.2% versus 75.6%, respectively). No individuals among those primarily referred for hysterectomy opted for cryopreservation of oocytes. Among transgender men, young age, no previous hormonal treatment and stating homosexual orientation were independent factors associated with the decision to cryopreserve oocytes. Among transgender women, the decision to undergo gender affirmation surgery and stating heterosexual orientation were independent factors associated with a decision to refrain from fertility preservation. Fertility treatments, using IUI or IVF with donor sperm, were mainly performed in partners of transgender men. Ten live births were reported in the group of transgender men and two for transgender women.

LIMITATIONS, REASONS FOR CAUTION

The main limitation is the retrospective nature of the study, with missing data for many variables. The short study period and the study population being too young to permit observation of long-term outcomes of fertility preservation and fertility treatments are reasons for caution.

WIDER IMPLICATIONS OF THE FINDINGS

Our results confirm that fertility preservation has been requested by transgender people since the change in Swedish legislation in 2013. Information about aspects of fertility early in the transition process is important, since hormonal and surgical treatments may have a large impact on the decision to undergo fertility preservation. It is important to train fertility clinic staff to identify and handle the specific obstacles, as well as address the need for information and support that transgender people may have when planning for fertility preservation, fertility treatment and pregnancy.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by a grant from the Swedish state, under the ALF agreement between the Swedish government and the county councils (ALFGBG-720291), and by Hjalmar Svensson’s Research Foundation. None of the authors has any conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Transgender and Gender Diverse Fertility Choices: Supporting the Decision-Making Process for Adolescents and Young Adults

OBJECTIVE

To qualitatively examine the fertility-related decision making process of transgender and gender diverse (TGD) adolescents and young adults (AYAs) and their parents, in the setting of pursing gender affirming treatments.

STUDY DESIGN

Twenty-five TGD AYAs and 6 parents of TGD AYAs participated in a focus group or individual semistructured interviews focused on participants' experience learning about the effects of gender affirming treatments on fertility as well as the process of making a fertility preservation decision. Using open coding, data were analyzed in an iterative process identifying emerging themes and relationships. A decisional satisfaction score was collected and/or coded for each participant.

RESULTS

Four broad themes related to the decision-making process were identified: (1) Critical steps include awareness, gathering information, and conversations; (2) External constraints limit choices; (3) Expanding the conversation beyond preservation; and (4) Emotional distress, conflict, and decisional satisfaction. Despite reporting emotional distress or conflict during the decision, TGD AYAs and parents of TGD AYAs generally reported a high level of satisfaction with their fertility preservation decision.

CONCLUSIONS

There are specific ways health care professionals and family members can support TGD AYAs in their fertility-related decision making process. Decisional satisfaction was common, regardless of whether TGD AYAs chose to pursue fertility preservation or not.

Current use of testosterone therapy in LGBTQ populations

Testosterone therapy (TT) is a type of gender-affirming hormone therapy (GAHT) in lesbian, gay, bisexual, transgender, and genderqueer (LGBTQ) populations for gender dysphoria (GD), body uneasiness, and sexual dysfunction. The physical and physiological effects of TT vary widely depending on the dosing regimen and duration of treatment. An individualized approach prioritizing patient-specific desired effects in the context of pre-existing characteristics and health history is strongly recommended. Although TT is an effective treatment for many patients, there has been an increase in the illegitimate acquisition of TT in recent years. Non-judicious prescribing and lack of physician surveillance increases the risk of unintended side effects and potential serious health consequences.

Adolescent Fertility Preservation: Where Do We Stand Now

Adolescence is a period of flux for many body systems. While fertility potential typically increases after menarche, there are diseases where the opposite occurs and fertility preservation options need to be considered early. In cases of cancer, options vary by pubertal status and can include ovarian tissue cryopreservation, oocyte cryopreservation, sperm cryopreservation, and testicular tissue cryopreservation. Much remains to be learned about fertility and preservation options in those with differences in sexual development (DSDs); however, depending on the form of DSD, fertility preservation may not be necessary. Similarly, traditional fertility counseling in children with galactosemia may need to be changed, as data suggest that fertility rates attributed to other causes of premature ovarian insufficiency may not be as applicable to this disease. Adolescents with Turner's syndrome are at high risk for premature ovarian failure; therefore, it is important to consider options as early as possible since ovarian reserves are depleted quickly. On the other hand, transgender and gender diverse adolescents may even be able to undergo fertility preservation after starting hormone therapy. In all cases, there are additional ethical components including technical/surgical risks in childhood, offering experimental therapies without creating false hope and evaluating children's consent and assent capabilities that must be considered.

Fecundity in transgender men

ABSTRACT

Premenopausal transgender men who retain internal female reproductive organs, who use exogenous testosterone, and who are sexually active with cisgender men are often capable of conception. This article discusses the potential for fecundity in transgender men, as well as appropriate reproductive care depending on whether the patient prefers to avoid conception or to become pregnant.

Transgender men's fertility preservation: experiences, social support, and the quest for genetic parenthood

Transgender people assigned female at birth may undergo fertility preservation by egg or embryo freezing, usually prior to gender affirming treatment. In this binational ethnographic study, four transgender men were included as part of a larger comparative project on fertility preservation. In-depth ethnographic interviews allowed informants to talk freely about their fertility preservation experiences, and the circumstances that had enabled them to pursue this option. Prominent in men's accounts were the importance of genetic parenthood and the role of social support from others in the fertility preservation process. Indeed, in all cases, social support-from parents, siblings, partners, peers, physicians and employers-was critical, effectively enabling young transgender men to embark on their fertility preservation journeys and undergo the physically taxing process. This study illustrates the power of thriving through relationships that were critical in young transgender men's experiences of fertility preservation.

Successful oocyte cryopreservation using letrozole as an adjunct to stimulation in a transgender adolescent after GnRH agonist suppression

OBJECTIVE

To report a successful case of ovarian hyperstimulation and oocyte cryopreservation in a transgender male adolescent after suppression with a gonadotropin-releasing hormone (GnRH) agonist while using the aromatase inhibitor letrozole to maintain low serum estradiol.

DESIGN

Case report.

SETTING

Division of Reproductive Endocrinology and Infertility, Washington University in St. Louis School of Medicine, St Louis, Missouri.

PATIENT(S)

A 15-year-old Tanner II transgender male adolescent with a GnRH agonist implant.

INTERVENTION(S)

The GnRH agonist implant was removed. The patient was given letrozole (5 mg daily) while undergoing ovarian stimulation with an antagonist protocol. After oocyte retrieval, the patient began taking testosterone.

MAIN OUTCOME MEASURE(S)

Successful oocyte cryopreservation with minimal changes in breast budding.

RESULT(S)

The patient's peak serum estradiol concentration was 510 pg/mL. Twenty-two mature oocytes were cryopreserved. Small increases in breast budding occurred between baseline and the time of oocyte retrieval.

CONCLUSION(S)

We successfully used letrozole to maintain low serum estradiol in a transgender male adolescent during ovarian stimulation. Maintaining low estradiol to minimize pubertal development and possibly prevent gender dysphoria symptoms may make oocyte cryopreservation more desirable for transgender male adolescents.

Short-term testosterone use in female mice does not impair fertilizability of eggs: implications for the fertility care of transgender males

STUDY QUESTION

Does testosterone use in females affect reproductive potential, particularly with regard to the production of fertilizable gametes?

SUMMARY ANSWER

Testosterone (T) injections given to post-pubertal female mice caused virilization and although the ovaries were smaller than controls they were still responsive and produced fertilizable eggs when superovulated.

WHAT IS KNOWN ALREADY

Studies to examine the effects of testosterone on reproductive potential in transgender males are lacking. Recently, a model was developed that simulates many aspects of testosterone use in transgender males in order to look at reproductive effects of testosterone in female mice. This study found masculinizing effects on the mice but did not find significant deficits on the number of ovarian follicles; however, effects of testosterone use on ovarian stimulation and fertilizability of oocytes were not investigated.

STUDY DESIGN, SIZE, DURATION

A total of 66, 6-week-old Hsd:NSA (CF-1) female mice and six Hsd:ICR (CD-1) male mice were used for this study. Mice were injected s.c. with 400 µg T or sesame oil once a week for 6 weeks and were either killed 1 week after the sixth injection (active exposure group), or 6-7 weeks after the final T injection (washout group).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Both active exposure and washout groups were further subdivided into three groups: unstimulated, equine CG (eCG)-stimulated or eCG/hCG-stimulated. eCG-stimulated mice were killed 44-48 h after eCG injection. eCG/hCG-stimulated mice were injected with eCG, followed 48 h later with hCG. Mice were killed ∼13-18 h after the hCG injection. Data collected included daily vaginal cytology, terminal testosterone levels, ovary weights and histology, number of oocytes/eggs collected in each group, and cleavage to the two-cell stage following IVF.

MAIN RESULTS AND THE ROLE OF CHANCE

Testosterone-treated mice had testosterone levels elevated to the level of male mice and ceased cycling. Ovaries were significantly smaller in testosterone-treated mice, but they contained normal cohorts of follicles and responded to gonadotrophin stimulation by ovulating similar numbers of eggs as controls, that fertilized and cleaved in vitro.

LIMITATIONS, REASONS FOR CAUTION

Mice were treated for only 6 weeks, whereas many transgender men use testosterone for many years before considering biological children, and developmental competence was not assessed. Importantly, a mouse system may not perfectly simulate human reproductive physiology.

WIDER IMPLICATIONS OF THE FINDINGS

The current standard of care for transgender men who desire biological children is to cease testosterone therapy prior to ovarian stimulation, but the necessity for stopping testosterone is not known. Our model demonstrates that it is possible for testosterone-suppressed ovaries to respond to gonadotrophic stimulation by producing and ovulating fertilizable eggs, thereby obviating the need for testosterone cessation prior to ovarian stimulation. In time, these results may provide insights for future clinical trials of fertility treatment options for transgender men.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Reproductive Endocrinology and Infertility fellowship program through UConn Health Graduate Medical Education (to C.B.B.). The authors have no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Maternal Health in the Transgender Population

Social acceptance and legal protections for transgender and gender nonconforming patients have increased over the past decade, but significant health care disparities still remain. Such an area of disparity is discussion with and interventions for fertility, contraception, pregnancy, and lactation in TGNC patients. Providing optimal care starts with creating a welcoming and safe environment. Appropriate preconception education includes the effects of gender-affirming therapies (both surgical and nonsurgical) on fertility as well the fertility preservation techniques that are available. However, as gamete retrieval requires natal hormone stimulation, gender dysphoria may be worsened. Thus, these patients should be carefully monitored not only medically, but also with regard to their mental health. In addition to assisted reproductive technologies, protocols exist to aid with induction of lactation as well as discontinuation if desired. As this is a growing field of medicine with limited data available on safety and long-term outcomes, recommendations are for a multidisciplinary team approach to ensure patients' safety and well-being.

Medical transition for gender diverse patients

Purpose of review

The purpose of this review is to provide an up-to-date overview of gender-affirming hormone therapy, including the various hormone regimens available, the efficacy and potential risks of these treatments, and considerations for surveillance and long-term care.

Recent findings

Recent studies reaffirm that hormone therapy has positive physical and psychological effects for many transgender individuals. The overall risks of treatment are low. Transgender women may have an increased risk of venous thromboembolism and breast cancer based on recent cohort studies, but these findings have yet to be confirmed with randomized controlled trials. Important long-term considerations include metabolic, cardiovascular, and skeletal health.

Summary

High-quality, long-term studies on the effectiveness and safety of various gender-affirming hormone treatment regimens are lacking, but the currently available evidence suggests that it is overall safe and effective with appropriate oversight.

Creating Affirmative and Inclusive Practices When Providing Genetic and Genomic Diagnostic and Research Services to Gender-Expansive and Transgender Patients

BACKGROUND

Gender expansive and transgender (GET) healthcare extends beyond gender-affirming therapies, reaching every medical specialty and subspecialty. As the number of GET patients seeking health services has increased, so has the need for standards of care regarding GET-affirmative practices throughout the healthcare system. As such, the number of publications surrounding GET-affirmative practices has steadily risen. However, even as such research has gained ground in other areas, one realm in which there has been a relative lag is genetics and genomics (GG).

CONTENT

In this article, we track the GET patient and their laboratory sample from the clinic to the GG laboratory and back. Throughout the preanalytical, analytical, and postanalytical phases, we identify publications, recommendations, and guidelines relevant to the care of the GET community. We also identity knowledge gaps in each area and provide recommendations for affirmative and inclusive processes for addressing those gaps.

SUMMARY

We have identified the practices involved in GG services that would benefit from GET-affirmative process improvement, reviewing relevant affirmative guidelines. Where guidelines could not be found, we identified those knowledge gaps and suggested potential solutions and future directions for implementing GET-affirmative practices.

Formative development of a fertility decision aid for transgender adolescents and young adults: a multidisciplinary Delphi consensus study

PURPOSE

No educational and decision support tools exist to aid transgender and non-binary (TNB) adolescents and young adults (AYA) in making decisions about fertility preservation in the context of initiating gender-affirming medical care that can impair fertility. This study identified critical content areas and learning objectives to include in a decision aid about fertility preservation targeted for TNB AYA.

METHODS

Delphi methodology was leveraged to engage 80 multidisciplinary experts in reproductive medicine and pediatric transgender health care in a two round consensus building procedure. Proposed content areas rated as "probably keep" or "definitely keep" by 75% of experts were retained. Proposed learning objectives reaching 75% agreement on ratings of importance and priority were also identified.

RESULTS

The Delphi procedure identified five priority content areas (Basic Reproduction; Gender-Affirming Medical Interventions: Impacts on Fertility; Established Fertility Preservation Options; Benefits and Risks of Established Fertility Preservation Procedures; Alternative Pathways to Parenting) and 25 learning objectives to prioritize in a fertility-related decision aid for TNB AYA.

CONCLUSION

A multidisciplinary panel of experts achieved agreement around content areas and learning objectives to incorporate into a decision aid about fertility preservation for TNB AYA.

ABM Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Fertility preservation in a transgender man without prolonged discontinuation of testosterone: a case report and literature review

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.

Impact of Exogenous Testosterone on Reproduction in Transgender Men

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.

Fertility preservation options for transgender individuals

Gender affirming medical and surgical treatments affect the reproductive potential of transgender individuals. Prior to the development of assisted reproductive technologies (ART), genital gender-affirming surgery frequently eliminated a patient’s reproductive potential. Today, all patients should be counseled on their fertility preservation (FP) options before medical and surgical transition, yet this appears to seldom occur in practice. The following review is the result of a systematic literature search of PubMed, Medline and Google Scholar to identify current and future FP options, barriers to treatment patients face, practice patterns of transgender health care providers, and if there were any standardized counseling protocols. Options for transwomen at any point in their transition range from simply providing a semen sample to be used with assistive reproductive techniques to experimental techniques involving testicular cryopreservation followed by in vitro initiation of spermatogenesis. Transmen before and after starting hormone therapy can pursue any assistive reproductive techniques available for ciswomen. Future options currently under investigation include ovarian tissue cryopreservation (OTC) with in vitro oocyte maturation. In addition to counseling about their FP options, patients should be advised prospectively about the requirements, process details, the total costs associated with achieving pregnancy, and the inherent risks associated with using preserved genetic material including risk of failure, and maternal and fetal health risks. Transgender patients report using assistive reproductive services difficult, due to a lack of dialogue about fertility and the lack of information offered to them- presumably because their circumstances do not fit into a traditional narrative familiar to providers. Physicians and health care providers would benefit from better educational tools to help transgender patients make informed decisions and better training about transgender patients in general, and FP options available to them.