P-506 Reflecting on the Importance of Family Building and Fertility Preservation: Transgender People’s Experiences with Starting Gender-affirming Treatment as Adolescent

Study question

To investigate how adults of reproductive age (± 30 years), who started gender-affirming treatment during adolescence, reflect on their reproductive wishes.

Summary answer

Views regarding fertility and family building change over time, which may be related with reduced levels of gender dysphoria, matured intellectual and emotional cognitions.

What is known already

Within the last two decades, gender-affirming care for transgender youth has become widely available. One of the topical debates in adolescent transgender care concerns the difficulty of making decisions regarding fertility at an early age, since medical treatment for gender dysphoria negatively affects reproductive function. In transgender adolescents, data on the potential change in wishes and desires regarding fertility, family building and the importance of biological parenthood, when coming of reproductive age, are lacking. Hereby, the long-term consequences of acquired infertility in transgender adolescents who have now reached adulthood remain still unknown.

Study design, size, duration

This was a questionnaire study. Gender diverse adolescents who presented between 1989 and 2000 and started medical transition, were recruited for participation. As well as gender diverse adolescents who commenced medical treatment with gonadotropin-releasing hormone agonist (GnRHa) prior to gender affirming hormone treatment (GAHT), at least 9 years ago. 89 participants were eligible for inclusion in the study cohort.

Participants/materials, setting, methods

Data were collected through an online survey, and a subsequent telephonic interview to validate the provided answers in the survey. The fertility questionnaire focused on different themes, such as fertility counseling at initiation of medical treatment, decision-making about fertility preservation, current feelings about infertility, and a potential desire to have children.

Main results and the role of chance

The cohort consisted of 89 participants, among whom 66 trans masculine and 23 trans feminine people. Participants had a mean age of 32.4 years (SD 6.6, range 25.5-51.2) at time of the study, and 15.6 years (SD 2.2, range 11.5-20.6) at time of start of medical treatment. Since all participants initiated medical treatment before 2014, at that time laws requiring sterilization for legal gender recognition were still in place. Only 30% of participants received information about the options for fertility preservation, and none of them pursued fertility preservation. In addition, 96% of participants underwent gonadectomy and thus became permanently infertile. 27% of participants found becoming infertile troublesome, and 21% stated that they were not able to make decisions regarding fertility and future family building during adolescence. With today’s knowledge, 14% of trans masculine and 17% of trans feminine people would not have chosen to undergo gonadectomy. In addition, 44% of trans masculine and 35% of trans feminine people would pursue fertility preservation. The percentage of participants with a (future) desire for children changed from 34% at start of medical treatment to 56% at time of this study, of whom 23% had already started a family.

Limitations, reasons for caution

Since the participants reflect on a period in time in which fertility counseling was not offered on a structural basis and preservation options were not widely available, results of this study may not be fully translatable to current practice.

Wider implications of the findings

Transgender adolescents should be counselled on fertility and the options for fertility preservation, even in the absence of a desire for children upon initiation of treatment. Views on future family building might change over time, fertility counseling should be repeated at each step of the transition.

Trial registration number

na

P-444 Outcomes of oocyte vitrification in trans masculine persons

Study question

What are the outcomes of oocyte vitrification treatment(OVT) in trans masculine persons (TMPs) prior to, and after testosteroneuse? And how do these patients reflect on their treatment?

Summary answer

TMPs show a normal response to controlled ovarian hyperstimulation(COH). Even though the OVT was considered burdensome, most patients were satisfied with their treatment and outcome.

What is known already

The desire to parent genetic offspring is a relevant topic in the lives of many TMPs. To preserve their fertility prior to gender affirming hormone treatment or –surgeries, fertility preservation should be discussed by healthcare providers. However, the procedure may lead to an increase in dysphoric distress in TMPs. Only few studies have been published describing the outcomes of TMPs undergoing OVT. Their data suggest a comparable oocyte retrieval number in TMPs compared to cis gender women as well as similar fertilization and pregnancy rates. Outcomes of OVT in TMPs and their experiences undergoing said treatment remain under-explored.

Study design, size, duration

This single center, retrospective cohort study was performed by the Center of Expertise on Gender and the fertility clinic at the Amsterdam UMC, location VUmc, Amsterdam, the Netherlands. Between January 2017 and June 2021, all TMPs who had undergone OVT where approached for participation and 24/30 TMPs were included in our cohort.

Participants/materials, setting, methods

Demographic characteristics and data on OVT were retrieved from the medical records. Oocyte vitrification at our center is performed in persons between the age of 16 and 39 using a long agonist COH protocol. TMPs who had initiated testosterone were advised 3 months cessation prior to stimulation. Evaluation of the oocyte vitrification procedure was collected via an online questionnaire comprising of 10 multiple choice and open ended questions.

Main results and the role of chance

The median age and BMI of participants was 21.1 years (IQR 19.4 – 24.1) and 22.1 kg/m2 (IQR 20.8 – 25.4), respectively. Seven persons were using testosterone, two persons were using puberty suppression (GnRH analogues) and seven persons were using other hormonal cycle regulation prior to their OVT.

The median anteral follicle count on cycle day three was 28(IQR 24.5 – 35.0). After a median of 12 FSH stimulation days (IQR 10 – 13), a trigger was administered. The mean peak serum estradiol(E2) was 11062 pmol/L (SD 5385). A median of 20 oocytes (IQR 16 – 26) were found and a median of 17 oocytes (IQR 14 – 22) were frozen. Six participants (25%) developed an ovarian hyperstimulation syndrome(OHSS). Four of which were classified as severe. There were no significant differences between the prior testosterone users and non-testosterone users.

The median time between OPU and taking the questionnaire was 19.2 months(IQR 3.2 – 27.5). The response rate was 100%. Almost half of participants(46%) were most anxious for the internal examination prior to starting OVT. Interestingly, afterwards only 13% described the internal examination as the most strenuous part of the treatment. Hormone injections were considered the most strenuous part of OVT (29%).

Limitations, reasons for caution

A limitation of this study is the small sample size, especially when comparing prior testosterone users to non-testosterone users. Another limitation is that the effect of previous testosterone on the chance of live birth rate remains unknown since no participants have chosen to pursue conception yet.

Wider implications of the findings

This is the first study describing OVT outcomes in the TMPs in the Netherlands. This study shows no difference between prior testosterone use or not. The survey results identify the most burdensome aspect of the procedure for TMPs and improve transgender specific fertility strategies.

Trial registration number

not applicable

Histological study on the influence of puberty suppression and hormonal treatment on developing germ cells in transgender women

STUDY QUESTION

Can transgender women cryopreserve germ cells obtained from their orchiectomy specimen for fertility preservation, after having used puberty suppression and/or hormonal treatment?

SUMMARY ANSWER

In the vast majority of transgender women, there were still immature germ cells present in the orchiectomy specimen, and in 4.7% of transgender women—who all initiated medical treatment in Tanner stage 4 or higher—mature spermatozoa were found, which would enable cryopreservation of spermatozoa or testicular tissue after having used puberty suppression and/or hormonal treatment.

WHAT IS KNOWN ALREADY

Gender affirming treatment (i.e. puberty suppression, hormonal treatment, and subsequent orchiectomy) impairs reproductive function in transgender women. Although semen cryopreservation is generally offered during the transition process, this option is not feasible for all transgender women (e.g. due to incomplete spermatogenesis when initiating treatment in early puberty, in case of inability to masturbate, or when temporary cessation of hormonal treatment is too disruptive). Harvesting mature spermatozoa, or testicular tissue harboring immature germ cells, from orchiectomy specimens obtained during genital gender-affirming surgery (gGAS) might give this group a chance of having biological children later in life. Previous studies on spermatogenesis in orchiectomy specimens showed conflicting results, ranging from complete absence of germ cells to full spermatogenesis, and did not involve transgender women who initiated medical treatment in early- or late puberty.

STUDY DESIGN, SIZE, DURATION

Histological and immunohistochemical analyses were performed on orchiectomy specimens from 214 transgender women who underwent gGAS between 2006 and 2018. Six subgroups were identified, depending on pubertal stage at initiation of medical treatment (Tanner stage 2-3, Tanner stage 4-5, adult), and whether hormonal treatment was continued or temporarily stopped prior to gGAS in each of these groups.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All transgender women used a combination of estrogens and testosterone suppressing therapy. Orchiectomy specimen sections were stained with Mayer’s hematoxylin and eosin and histologically analyzed to assess the Johnsen score and the ratio of most advanced germ cell types in at least 50 seminiferous tubular cross-sections. Subsequently, immunohistochemistry was used to validate these findings using spermatogonia, spermatocytes or spermatids markers (MAGE-A3/A4, γH2AX, Acrosin, respectively). Possibilities for fertility preservation were defined as: preservation of spermatozoa, preservation of spermatogonial stem cells or no possibilities (in case no germ cells were found). Outcomes were compared between subgroups and logistic regression analyses were used to assess the association between the duration of hormonal treatment and the possibilities for fertility preservation.

MAIN RESULTS AND THE ROLE OF CHANCE

Mature spermatozoa were encountered in 4.7% of orchiectomy specimens, all from transgender women who had initiated medical treatment in Tanner stage 4 or higher. In 88.3% of the study sample orchiectomy specimens only contained immature germ cells (round spermatids, spermatocytes or spermatogonia, as most advanced germ cell type). In 7.0%, a complete absence of germ cells was observed, all these samples were from transgender women who had initiated medical treatment in adulthood. Cessation of hormonal treatment prior to gGAS did not affect the presence of germ cells or their maturation stage, nor was there an effect of the duration of hormonal treatment prior to gGAS.

LIMITATIONS, REASONS FOR CAUTION

Since data on serum hormone levels on the day of gGAS were not available, we were unable to verify if the transgender women who were asked to temporarily stop hormonal treatment 4 weeks prior to surgery actually did so, and if people with full spermatogenesis were compliant to treatment.

WIDER IMPLICATIONS OF THE FINDINGS

There may still be options for fertility preservation in orchiectomy specimens obtained during gGAS since a small percentage of transgender women had full spermatogenesis, which could enable cryopreservation of mature spermatozoa via a testicular sperm extraction procedure. Furthermore, the vast majority still had immature germ cells, which could enable cryopreservation of testicular tissue harboring spermatogonial stem cells. If maturation techniques like in vitro spermatogenesis become available in the future, harvesting germ cells from orchiectomy specimens might be a promising option for those who are otherwise unable to have biological children.

STUDY FUNDING/COMPETING INTEREST

None.

TRIAL REGISTRATION NUMBER

N/A.

O-138 Reproductive performance of women with and without intrauterine adhesions following recurrent dilatation and curettage for miscarriage: long-term follow-up of a randomized controlled trial

Study question

Are the long-term reproductive outcomes following recurrent dilatation and curettage (D&C) for miscarriage in women with identified and treated intrauterine adhesions (IUAs) comparable to women without IUAs.

Summary answer

Reproductive outcomes in women with identified and treated IUAs following recurrent D&C for miscarriage are impaired compared to women without IUAs.

What is known already

The Prevention of Adhesions Post Abortion (PAPA) study showed that application of auto-crosslinked hyaluronic acid (ACP) gel, an absorbable barrier in women undergoing recurrent D&C for miscarriage resulted in a lower rate of IUAs, 13% versus 31% (relative risk 0.43, 95% CI 0.22 to 0.83), lower mean adhesion score and significant less moderate to severe IUAs. It is unclear what the impact is of IUAs on long-term reproductive performance.

Study design, size, duration

This was a follow-up of the PAPA study, a multicenter randomized controlled trial evaluating the application of ACP gel in women undergoing recurrent D&C for miscarriage. All included women received a diagnostic hysteroscopy 8–12 weeks after randomization to evaluate the uterine cavity and for adhesiolysis if IUAs were present. Here, we present the reproductive outcomes in women with identified and treated IUAs versus women without IUAs, 46 months after randomization.

Participants/materials, setting, methods

Between December 2011 and July 2015, 152 women with a first-trimester miscarriage with at least one previous D&C, were randomized for D&C alone or D&C with immediate intrauterine application of ACP gel. Participants were approached at least 30 months after randomization to evaluate reproductive performance, obstetric and neonatal outcomes and cycle characteristics. Main outcome was ongoing pregnancy. Outcomes of subsequent pregnancies, time to conception and time to live birth were also recorded.

Main results and the role of chance

In women pursuing a pregnancy, 14/24 (58%) ongoing pregnancies were recorded in women with identified and treated IUAs versus 80/89 (90%) ongoing pregnancies in women without IUAs odds ratio (OR) 0.18 (95% CI 0.06 to 0.50, P-value <0.001). Documented live birth was also lower in women with IUAs; 13/24 (54%) with versus 75/89 (84%) without IUAs, OR 0.22 (95% CI: 0.08 to-0.59, P-value 0.004). The median time to conception was 7 months in women with identified and treated IUAs versus 5 months in women without IUAs (hazard ratio (HR) 0.84 (95% CI 0.54 to 1.33)) and time to conception leading to a live birth 15 months versus 5.0 months (HR 0.54 (95% CI: 0.30 to 0.97)). In women with identified and treated IUAs, premature deliveries were recorded in 3/16 (19%) versus 4/88 (5%) in women without IUAs, P-value 0.01. Complications were recorded in respectively 12/16 (75%) versus 26/88 (30%), P-value 0.001. No differences were recorded in mean birth weight between the groups.

Limitations, reasons for caution

In the original PAPA study, randomization was applied for ACP gel application. Comparing women with and without IUAs is not in line with the randomization and therefore confounding of the results cannot be excluded. IUAs, if visible during routine hysteroscopy after randomization were removed as part of the study protocol.

Wider implications of the findings

As IUAs have an impact on reproductive performance, even after hysteroscopic adhesiolysis, primary prevention is essential. Expectative and medical management should therefore be considered as serious alternatives for D&C in women with a miscarriage. In case D&C is necessary, application of ACP gel should be considered.

Trial registration number

Netherlands Trial Register NTR 3120.

Impaired semen quality in trans women: prevalence and determinants

STUDY QUESTION

What is the semen quality in trans women at time of fertility preservation, prior to the start of gender-affirming hormone treatment?

SUMMARY ANSWER

Before the start of gender-affirming hormone treatment, semen quality in trans women was already strongly decreased compared to the general population.

WHAT IS KNOWN ALREADY

Hormone treatment for -trans women (birth-assigned males, female gender identity) consists of anti-androgens combined with estrogens in order to achieve feminization and it is accompanied by a loss of reproductive capability. Trans women can opt for semen cryopreservation prior to their medical transition to retain the possibility to parent genetically related offspring. Post-thaw semen parameters determine which ART can be used. Knowledge of semen quality and the factors negatively influencing semen parameters in trans women are important to improve semen quality before fertility preservation.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study was performed between 1972 and 2017. In total, 260 trans women were included for this study. Due to the study design, there was no loss to follow-up or attrition.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We studied the quality of the preserved semen in trans women, prior to their medical transition, who visited our gender clinic. Semen parameters were collected, as well as data on age, alcohol consumption, smoking, cannabis use, BMI, previous use of estrogens or anti-androgens and endocrine laboratory results. Semen parameters were categorized using reference values for human semen of the World Health Organization (WHO) and compared with data from the general population. Logistic regression analyses were performed to analyze the extent to which factors known to have a negative impact on semen quality in the general population explained the impaired semen quality in the cohort.

MAIN RESULTS AND THE ROLE OF CHANCE

The cohort consisted of 260 trans women between the age of 16 and 52 years. Semen quality in trans women was significantly decreased compared to WHO data from the general population. In total, 21 trans women had an azoospermia and median semen parameters for the remaining trans women and the general population, respectively, were as follows: volume 2.7 and 3.2 ml (P < 0.05), sperm concentration 40 and 64 million/ml (P < 0.05), total sperm number 103 and 196 million (P < 0.05) and progressive motility 41% and 57% (P < 0.05). Smoking (odds ratio (OR) 2.35 (95% CI 1.06–5.21)) and a higher age at time of fertility preservation (OR 1.04 (95% CI 1.00–1.08)) were found to correlate with an impaired progressive motility. Twelve trans women reported to have used anti-androgens and estrogens, and all had discontinued for at least 3 months prior to the first attempt for semen cryopreservation. No correlation was found between previous gender-affirming hormone use and decreased semen parameters. The median post-thaw total motile sperm count was 1.0 million per vial (interquartile range 0.1–3.1) and in only 26.4% of thawed semen samples was the quality adequate for a minimally invasive IUI.

LIMITATIONS, REASONS FOR CAUTION

Limitations include the retrospective design and insufficient data on transgender-specific factors, such as bringing the testes into the inguinal position (tucking), wearing tight underwear and low masturbation frequency.

WIDER IMPLICATIONS OF THE FINDINGS

Semen quality in trans women was decreased compared to the general population, which could not be explained by known risk factors, such as BMI, alcohol consumption, cannabis use, gender-affirming hormone use or abnormal endocrine laboratory results. Although a negative impact of smoking was observed, it was insufficient to explain the overall decreased semen quality in this cohort. Since low pre-freeze semen quality results in an even lower post-thaw semen quality, the majority of trans women and their female partner or surrogate may need an invasive and burdensome treatment to establish a pregnancy.

STUDY FUNDING/COMPETING INTEREST(S)

For this study, no external funding was obtained and there were no competing interests.

TRIAL REGISTRATION NUMBER

NA.

Retrospective observational RT-PCR analyses on 688 babies born to 843 SARS-CoV-2 positive mothers, placental analyses and diagnostic analyses limitations suggest vertical transmission is possible

Research question

Is there vertical transmission (from mother to baby antenatally or intrapartum) after SARS-CoV-2 (COVID-19) infected pregnancy?

Study design

A systematic search related to SARS-CoV-2 (COVID-19), pregnancy, neonatal complications, viral and vertical transmission. The duration was from December 2019 to May 2020.

Results

A total of 84 studies with 862 COVID positive women were included. Two studies had ongoing pregnancies while 82 studies included 705 babies, 1 miscarriage and 1 medical termination of pregnancy (MTOP). Most publications (50/84, 59.5%), reported small numbers (<5) of positive babies. From 75 studies, 18 babies were COVID-19 positive. The first reverse transcription polymerase chain reaction (RT-PCR) diagnostic test was done in 449 babies and 2 losses, 2nd RT-PCR was done in 82 babies, IgM tests were done in 28 babies, and IgG tests were done in 28 babies. On the first RT-PCR, 47 studies reported time of testing while 28 studies did not. Positive results in the first RT-PCR were seen in 14 babies. Earliest tested at birth and the average time of the result was 22 hours. Three babies with negative first RT-PCR became positive on the second RT-PCR at day 6, day 7 and at 24 hours which continued to be positive at 1 week.

Four studies with a total of 4 placental swabs were positive demonstrating SARS-CoV-2 localised in the placenta. In 2 studies, 10 tests for amniotic fluid were positive for SARS-CoV-2. These 2 babies were found to be positive on RT-PCR on serial testing.

Conclusion

Diagnostic testing combined with incubation period and placental pathology indicate a strong likelihood that intrapartum vertical transmission of SARS-CoV-2 (COVID-19) from mother to baby is possible.

High-quality human preimplantation embryos actively influence endometrial stromal cell migration

Purpose

The purpose of this paper is to study whether human preimplantation embryos regulate endometrial stromal cell (hESC) migration.

Methods

Primary hESCs were isolated from fertile patients undergoing hysterectomy for benign conditions (uterine scar niche n = 3, dysmenorrhea n = 2; no hormonal treatment). Migration and proliferation assays were performed by culturing decidualized or non-decidualized hESCs in the presence of embryo conditioned medium (ECM) from high-quality embryos (fragmentation ≤ 20%) or from low-quality embryos (fragmentation > 20%) or in non-conditioned medium from the same dishes (control). ECM samples from 425 individually cultured human embryos were used in this study.

Results

ECM from high-quality embryos, i.e., with a low percentage of fragmentation, actively stimulated decidualized hESC migration (p < 0.001). This effect was consistent throughout embryonic development from cleavage stage embryos with 2–7 cells (high quality vs. control; p = 0.036), 8–18 cells (high quality vs. control; p < 0.001) to morulae (high quality vs. control; p = 0.003). Additionally, linear regression analysis showed that hESC migration was influenced by embryo quality (fragmentation, β − 0.299; p = 0.025) and not developmental stage (cell number, β 0.177; p = 0.176) or maternal age (β − 0.036; p = 0.78). Opposite to decidualized hESCs, the migration response of non-decidualized hESCs was inhibited by ECM from high-quality embryos (p = 0.019). ECM from low-quality embryos, i.e., with a high percentage of fragmentation, did not cause an altered migration response in decidualized hESCs (p = 0.860) or non-decidualized hESCs (p = 0.986). Furthermore, ECM of both high- and low-quality human embryos did not influence the number of proliferating cells (p = 0.375) and the cell cycle time (p = 0.297) of non-decidualized or decidualized hESCs.

Conclusion

This study reveals a mechanism by which high-quality human preimplantation embryos actively interact with the endometrium to increase their chances of successful implantation.

Electronic supplementary material

The online version of this article (10.1007/s10815-017-1107-z) contains supplementary material, which is available to authorized users.