Predicting successful sperm retrieval in transfeminine adolescents after testicular biopsy

Pubertal Status at the Time of Fertility Preservation in Transgender Girls

BACKGROUND

Puberty blockade and gender-affirming hormone therapy can impair fertility. Counseling on fertility preservation is important before initiation of therapy. Our study aimed to assess Tanner staging and the presence of virilizing secondary sex characteristics at the time of sperm collection and correlate the viability of sperm with the Tanner staging and degree of virilization.

METHODS

A retrospective chart review of 23 transgender girls referred to pediatric urology at our academic pediatric transgender clinic for fertility preservation counseling was performed. At the initial visit before treatment, pubertal staging along with the assessment of virilizing secondary characteristics was performed. The semen analyses were evaluated for volume, sperm concentration, total sperm count, motility, and total motile count.

RESULTS

Of the first 23 transgender girls evaluated and counseled, 8 transgender females successfully produced a sperm sample for cryopreservation. The average testicular volume was 18.5 ml and ranged from 12 ml to 20 ml. The median semen parameters were at or above the 2021 World Health Organization threshold. The 8 transgender females who successfully underwent fertility preservation presented with at least 1 secondary sex characteristic. In 1 subject with Tanner stage 3 pubic hair development and a testicular volume of 12 ml, only voice change was reported. Facial hair and laryngeal prominence were not present on examination.

CONCLUSION

More than a third of our patients who accepted a referral to pediatric urology agreed to produce a sperm sample for cryopreservation. All of these patients successfully preserved sperm. With counseling and early referral to pediatric urology, a high percentage of fertility preservation in transgender girls was achieved.

Fertility preservation in transfeminine adolescents using TESE at the time of Histrelin Acetate subcutaneous implant placement: A Case Series

BACKGROUND

Fertility preservation (FP) is an important aspect of the care of transgender patients in whom Gender Affirming Medical Treatment (GAT) may begin before puberty is completed. While there are overall few studies that can be used to guide conversations about long-term effects of GAT, there are concerns that GAT could negatively impact fertility. Prior studies have shown low utilization of FP in this population, with avoidance of delay in starting GAT cited as one of the most common reasons for foregoing FP. It is possible that strategies to mitigate delay in commencement of GAT can facilitate higher FP utilization, maintaining options for future family building.

OBJECTIVE

To describe our institution's experience with Testicular Sperm Extraction (TESE) for FP and Histrelin Acetate (Supprelin) Subcutaneous Implantation for GAT commencement.

STUDY DESIGN

A retrospective review of transfeminine adolescents at our institution from 2010 to 2022 who underwent TESE for FP at the time of Supprelin placement for GAT (FP/SP). Outcomes of interest included successful sperm retrieval, age at first visit to our institution's Transgender Multispecialty Service Health clinic (GeMS), age at time of FP/SP, testicular volume, and Tanner stage at time of FP/SP, and age when GnRH agonist (GnRHa) therapy was prescribed. Testosterone, LH, FSH, and Inhibin B values prior to combination FP/SP were also obtained.

RESULTS

Ten patients from 2017 to 2022 underwent FP/SP after prescription of GnRHa based on Endocrine Society Guidelines. Successful sperm retrieval and storage was achieved in all patients. Median age at FP/SP was fourteen years 5.5 months (range 12y5m-16y8m). Median time from GnRHa prescription to FP/SP was two months (range 2-5 m). Mean testicular volume at time of FP/SP was 13.2 cc (SD 3.38 cc, range 8-17 cc), and median Tanner Stage was IV (range III-V). Average testosterone level was 301.60 (SD 173.04), LH 3.00 (SD 1.25), FSH 3.33 (SD 1.71), Inhibin B 208.50 (SD 87.44).

CONCLUSIONS

Performing TESE for FP is feasible for transgender youth undergoing Histrelin implant placement, leading to short delays in starting GAT. Testicular volume and endocrine markers can provide preoperative insight into likelihood of successful sperm retrieval during TESE, are needed to identify which patients will have successful sperm retrieval to ensure optimal counseling and informed decision making for providers, patients and families.

Fertility preservation and realignment in transgender women

Medical care for transgender people is multi-faceted and attention to individual reproductive aspirations and planning are an essential, yet often overlooked aspect of care. Given the impact of hormonal therapy and other gender affirmation procedures on reproductive function, extensive counselling and consideration of fertility preservation is recommended prior to their commencement. This review article explores the reproductive aspirations of transgender women and considers the current disparity between stated desires regarding utilisation of fertility preservation services. Current fertility preservation options and prospective treatments currently showing promise in the research arena are explored.

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.

Préservation de la fertilité chez les personnes transgenres

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