Outcomes of oocyte vitrification in trans masculine individuals

Current opinions invited review: testosterone and transgender medicine

PURPOSE OF REVIEW

Transgender individuals have a gender identity incongruent with their sex assigned at birth. Social, medical and surgical methods are often affirming. This review focuses on updates from the last 18 months mainly in testosterone use in masculinising gender-affirming hormone therapy (GAHT) in postpubertal adults, and also antiandrogens for suppression or blockade of endogenous testosterone in feminising GAHT. Mental and sexual healthcare are vital for many transgender patients, but are not the focus of this review.

RECENT FINDINGS

There has been a considerable increase in publications regarding testosterone GAHT in recent years, though narrative reviews, opinion pieces and case series continue to dominate. There has also been a notable increase in prospective studies and valuable data particularly from large longitudinal cohorts and studies aiming to refine GAHT prescribing and better understand long-term effects on aspects such as fertility, cardiometabolic and bone health as well as adverse effects.

SUMMARY

Testosterone GAHT is life changing. Increased research will help GAHT optimisation, and improve understanding of tissue-specific impacts and long-term safety. Longer-term data, prospective studies and utilisation of novel research tools and approaches are needed to enrich our understanding and prescribing of testosterone and its blockers in GAHT.

The attitudes of transgender and gender-diverse adolescents and their parents regarding fertility, parenthood, and fertility preservation before the start of puberty suppression or gender-affirming hormone therapy

BACKGROUND

Gender-affirming treatment for transgender and gender-diverse (TGD) adolescents can consist of puberty suppression (PS) and gender-affirming hormone treatment (GAHT), which may affect fertility.

AIM

This study aims to evaluate the attitudes and decision-making regarding parenthood and fertility preservation from TGD adolescents and their parents and analyze the fertility preservation use and outcome before the start of treatment.

METHODS

Adolescents under 18 starting PS or GAHT between November 2021 and March 2024 were enrolled in a multicenter prospective cohort study "ENIGI adolescents," conducted at Amsterdam University Medical Centre, Ghent University Hospital, and Florence University Hospital. Adolescents and parents were asked to complete the "Transgender Youth Fertility Attitudes Questionnaire" and the "Decision Conflict Scale." Information about fertility preservation use and outcomes was extracted from electronic patient files.

OUTCOMES

Attitudes from TGD adolescents and their parents regarding desire for children, fertility preservation use, outcomes, and decision-making.

RESULTS

A total of 316 adolescents were counseled about fertility options; 100 (49%) registered female at birth (RFAB) and 50 (48%) registered male at birth (RMAB) adolescents expressed a future desire for children. More than 1/3 had interest in or are still undecided about having a genetic offspring. None of the RFAB TGD adolescents underwent fertility preservation. In total, 20 (22%) RMAB adolescents pursued fertility preservation, 14 before PS and 6 before GAHT. Before PS, three performed testicular sperm extraction (TESE). All others performed semen cryopreservation. The post-thawed semen quality was low. The testicular volume and Tanner stage in the semen cryopreservation group were significantly higher compared to TESE, P = .013 and P = .021, respectively. There was no significant difference in age between those groups.Adolescents experience moderate to high decisional conflict about their fertility choices. RFAB adolescents experience a significantly higher conflict in decision-making compared to RMAB adolescents (40/100 vs 34/100 95% CI [2.1-9.4]). Younger RFAB adolescents experienced more decisional conflict (B =-1,25, 95% CI [-2,25, -0.25]). In RMAB this was not significant.

CLINICAL IMPLICATIONS

This study helps to further understand TGD adolescents' needs and can further improve the development of tailored fertility counseling.

STRENGTHS AND LIMITATIONS

This is the first European collaborative study on transgender healthcare in adolescents. A limitation of our study is the relatively low response rate to the questionnaires, which varied between 25% and 62%.

CONCLUSION

Many TGD adolescents express a desire for future parenthood yet experience decisional conflict about their reproductive options, even after receiving comprehensive fertility counseling prior to PS or GAHT.

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.

Longitudinal reproductive healthcare pathways of transmasculine people

BACKGROUND

It is recommended that transgender and gender diverse people receive fertility counselling before the start of gender affirming treatment. During this consultation their reproductive wishes and options for fertility preservation are explored. Transmasculine people have various options to fulfil their reproductive wishes also during gender-affirming treatment. Our aim is to study reproductive wishes and fertility preservation outcome in transmasculine people over time.

METHODS

Transmasculine individuals at the Centre of Expertise on Gender Dysphoria (CEGD) in Amsterdam were included in a prospective follow-up cohort study for gynaecological care and received follow-up questionnaires after 6, 12 and 24 months after fertility counselling regarding their reproductive wishes and fertility preservation. Reproductive outcomes were collected from the patient's medical files.

RESULTS

In total, 317 had a fertility consultation at the CEGD, of whom 10% underwent oocyte cryopreservation, 4% cortex preservation, 1% carried a pregnancy, and 12% underwent an ovariectomy. The most common reproductive choices are opting to preserve their internal organs and no fertility preservation wish. During a 2-year follow-up period, reproductive wishes changed in 20% of the participants. This was not related to age, testosterone use or prior puberty suppression. However, there was a trend suggesting that younger age and prior puberty suppression were related to changes in reproductive wishes.

CONCLUSION

This study showed reproductive wishes of transmasculine individuals over time. Further research is necessary to follow the reproductive outcomes of oocyte cryopreservation, cortex preservation and pregnancy. As well as, factors that influence their future pathway to parenthood.

Reproductive functions and fertility preservation in transgender men: A French case series

BACKGROUND

Transgender men face reproductive challenges due to the potential impact on fertility of gender-affirming hormone therapy (GAHT) and surgical interventions. Testosterone therapy during "female to male" transition leads to anovulation and amenorrhea. Although these effects are typically reversible upon stopping treatment, the long-term effects of androgens on future fertility and health of potential children remain poorly known. Despite being long overlooked, the desire for parenthood is a significant reality among transgender men. Advances in medical techniques and legislative changes now make fertility preservation (FP), primarily through oocyte cryopreservation, possible for transgender men. Yet, published data on FP outcomes for this population are still limited.

DESIGN

We conducted a retrospective study to compare ovarian stimulation outcomes between transgender men and presumed fertile women from an oocyte donation program.

RESULTS

Between June 2018 and February 2022, 118 transgender men were referred to the FP consultation, of whom 13 ultimately underwent FP through oocyte vitrification following ovarian stimulation. These 13 individuals were compared to a control group of 13 matched female oocyte donors. We did not observe any significant difference in the clinical and biological outcomes of ovarian stimulation, including duration of stimulation, total FSH dose administered, number of oocytes retrieved, and number of mature oocytes obtained.

CONCLUSION

Our experience suggests that FP through oocyte vitrification after ovarian stimulation is feasible and effective for transgender men, with outcomes comparable to those of cisgender women of the same age. Larger studies are necessary to validate these findings and assess the long-term success rates.

Transgender persons' view on previous fertility decision-making and current infertility: a qualitative study

STUDY QUESTION

How do adult transgender and gender diverse (TGD) people, who are infertile due to prior gender-affirming treatment, view their current infertility and their reproductive decisions made in the past?

SUMMARY ANSWER

In a time where sterilization was mandatory, transgender adolescents prioritized gender-affirming treatment over their future fertility and would make the same choice today despite emotional challenges related to infertility experienced by some.

WHAT IS KNOWN ALREADY

Under transgender law in the Netherlands, sterilization was required for legal gender recognition until 2014, resulting in permanent infertility. The long-term consequences of this iatrogenic infertility in transgender adolescents who have now reached adulthood remain underexplored.

STUDY DESIGN, SIZE, DURATION

Qualitative study design based on 21 in-depth one-on-one semi-structured interviews.

PARTICIPANTS/MATERIALS, SETTING, METHODS

TGD people in a stage of life where family planning may be a current topic were eligible for participation. They all received gender-affirming treatment in adolescence prior to the legislation change in 2014. A purposeful sampling technique was used from participants of another ongoing study. Eleven people assigned female at birth and ten people assigned male at birth were included. Interview transcripts were thematically analysed using a modified version of Braun and Clarke's six steps theory.

MAIN RESULTS AND THE ROLE OF CHANCE

Six main themes were generated: (i) personal considerations regarding fertility and fertility preservation in the past; (ii) external considerations regarding fertility and fertility preservation in the past; (iii) current vision on past considerations and decisions; (iv) Current experiences and coping with infertility; (v) future family building; (vi) advice regarding fertility and fertility preservation decision-making.

LIMITATIONS, REASONS FOR CAUTION

Selection, recall, and choice supportive bias may play a role in interpreting our results.

WIDER IMPLICATIONS OF THE FINDINGS

This study highlights the importance of tailored counselling and comprehensive information on fertility preservation for transgender individuals, especially adolescents, undergoing gender-affirming treatment.

STUDY FUNDING/COMPETING INTEREST(S)

N/A.

TRIAL REGISTRATION NUMBER

N/A.

A 10-year follow-up of reproductive outcomes in women attempting motherhood after elective oocyte cryopreservation

STUDY QUESTION

Which reproductive treatment outcomes are observed in women who underwent elective oocyte cryopreservation (EOC) and who returned to the clinic with a desire for a child?

SUMMARY ANSWER

Whether to warm oocytes or to first use fresh own oocytes for ART depends on age upon returning, but both strategies result in favorable reproductive outcomes.

WHAT IS KNOWN ALREADY

Most affluent countries have observed a trend toward postponement of childbearing, and EOC is increasingly used based on the assumption that oocytes cryopreserved at a younger age may extend a woman's reproductive lifespan and mitigate her age-related fertility decline. Although most follow-up studies after EOC have focused on women who requested oocyte warming, a substantial proportion of women who do not conceive naturally will embark on fertility treatment without using their cryopreserved oocytes. Reports on reproductive outcomes in past EOC users are scarce, and the lack of reproductive treatment algorithms in this group of women hampers counseling toward the most efficient clinical strategy.

STUDY DESIGN, SIZE, DURATION

This retrospective observational single-center study encompasses 843 women who had elective oocyte vitrification between 2009 and 2019 at our fertility clinic. Women who underwent fertility preservation for medical or oncological reasons were excluded. This study describes the outcomes of the diverse reproductive treatment strategies performed until May 2022 in women returning to our clinic to attempt motherhood.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Using descriptive statistics, patient characteristics and data of ovarian stimulation (OS) of EOC cycles were analyzed, as well as data related to OS and laboratory data of ART in women who pursued fertility treatment with and/or without using their cryopreserved oocytes. The primary outcome was live birth rate (LBR) per patient after oocyte warming and after ART using fresh oocytes. Secondary outcomes were return rate, utilization rate of the cryopreserved oocytes, laboratory outcomes upon return, and LBR per embryo transfer. A multivariable regression model was developed to identify factors associated with the decision to thaw oocytes as the primary strategy and factors associated with ongoing pregnancy upon return to the clinic.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1353 EOC cycles (mean ± SD, 1.6 ± 0.9 per patient) were performed. At the time of EOC, the mean age was 36.5 ± 2.8 years, mean anti-Müllerian hormone (AMH) was 2.3 ± 2.0 ng/ml, and 174 (20.6%) women had a partner. On average, 13.9 ± 9.2 mature oocytes were cryopreserved. Two hundred thirty-one (27.4%) women returned to the clinic, an average of 39.9 ± 23.4 months after EOC. Upon returning, their mean age was 40.4 ± 3.1 years, mean AMH was 1.5 ± 1.5 ng/ml, and 158/231 (68.3%) patients had a partner. As a primary approach, 110/231 (47.6%) past EOC users embarked on oocyte warming, 50/231 (21.6%) had intrauterine insemination, and 71/231 (30.7%) had ART using fresh own oocytes. Cumulative LBR (CLBR) was 45.9% (106/231) notwithstanding a miscarriage rate (MR) of 30.7% (51/166) in the entire cohort. In total, 141 women performed oocyte warming at some stage in their treatment trajectory. A subset of 90/231 (39.0%) patients exclusively had oocyte warming (41.6 ± 3.0 years, with 10.0 ± 5.2 oocytes warmed per patient). 52/231 (22.5%) patients exclusively had ART using fresh own oocytes (mean age of 39.0 ± 2.8 years, with 9.9 ± 7.4 mature oocytes retrieved per patient). CLBR was 37/90 (41.1%) in the oocyte warming-only group and 25/52 (48.1%) in the OS-only group. MR/transfer was 25.0% and 29.3% in the oocyte warming-only group and the OS-only group, respectively.

LIMITATIONS, REASONS FOR CAUTION

Both sample size and the retrospective design are limitations of this study. The decision to embark on a specific reproductive treatment strategy was based on patient preference, after counseling on their treatment options. This precludes direct comparison of the efficiency of reproductive treatment options in past EOC users in this study.

WIDER IMPLICATIONS OF THE FINDINGS

Reporting on clinical outcomes of women who underwent EOC and returned to the clinic to embark on divergent reproductive treatment strategies is mandatory to establish guidelines for best clinical practice in this growing patient population.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

N/A.