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

Outcome measurement for gender-affirming care in Canada: a systematic review

INTRODUCTION

Gender-affirming care (GAC) includes interventions aimed at supporting an individual's gender identity. Canada is experiencing an increase in referrals for GAC, higher than any other health service; therefore, there is a need for a systematic approach to health outcome measurement to effectively evaluate care. This review aims to analyse health outcome measurement in Canadian GAC, focusing on what is measured, how it is measured and associated barriers and enablers.

METHODS

A comprehensive search was conducted in MEDLINE, Embase, PsycINFO, Scopus and CINAHL, up to 26 December 2023. Inclusion criteria were original articles involving transgender or gender-diverse (TGD) patients receiving gender-affirming care in Canada.

RESULTS

A total of 4649 articles were identified with 64 included, representing 6561 TGD patients. Most studies were conducted in Ontario (52%), British Columbia (19%) and Quebec (11%). The most common forms of GAC provided were hormonal (36%) and surgical (27%). Barriers to outcome measurement include that most studies (61%) did not use patient-reported outcome measures (PROMs). When PROMs were used, most did not capture gender-related constructs (eg, gender dysphoria). Barriers to accessing care included stigma, discrimination, lack of clinician knowledge, geographic, socioeconomic and institutional barriers.

CONCLUSION

This review reveals gaps in outcome measurement for GAC, particularly underutilisation of PROMs and inconsistent outcome measurement and reporting. There is a need to systematically implement PROMs, including those measuring gender-related constructs, to promote patient-centred care. This review provides evidence-based recommendations for improving health outcomes for TGD individuals in Canada.

Fertility Intentions and Histories Among Transgender Adults Who Started Gender-Affirming Testosterone Before Adulthood

BACKGROUND

As more transgender adolescents and young adults seek gender-affirming care, questions persist about how their desire for potentially fertility-affecting treatment intersects with their fertility intentions.

METHODS

We surveyed 125 individuals born with a uterus and ovaries, living in the United States, initially prescribed gender-affirming testosterone at or before age 18, about their interest in genetically related children and history of fertility preservation and fertility-affecting procedures.

RESULTS

Twenty-two percent of respondents did not want children, and 47% wanted children but did not think a genetic relationship was important. Another 8% indicated having genetically related children was important and 17% indicated they did not know. Only 47% recalled counseling about fertility preservation. Those who might want genetically related children were less satisfied when they did not recall counseling (p = .001). Significantly more people in the group who might want genetically related children still had one or both ovaries (100% vs. 86%; p = .03), desired to carry a pregnancy in the future or were unsure (30% vs. 8%; p = .01), and either desired to use their eggs for genetically related children or were unsure (93% vs. 26%; p < .001).

CONCLUSIONS

More than one-half of individuals prescribed gender-affirming testosterone as adolescents had no interest in genetically related children. Those who were interested in genetically related children were more likely to have other fertility-preserving interests and behaviors, including potentially desiring a pregnancy and still having one or both ovaries. This finding suggests that fertility-related behaviors of individuals prescribed gender-affirming testosterone are in line with their stated goals.

Reproductive Health in Trans and Gender Diverse Patients: Effects of transmasculine gender-affirming hormone therapy on future reproductive capacity: clinical data, animal models, and gaps in knowledge

In brief

Animal studies are needed to inform clinical guidance on the effects of testosterone gender-affirming hormone therapy (T-GAHT) on fertility. This review summarizes current animal models of T-GAHT and identifies gaps in knowledge for future study.

Abstract

Testosterone gender affirming hormone therapy (T-GAHT) is frequently used by transgender and gender-diverse individuals assigned female at birth to establish masculinizing characteristics. Although many seek parenthood, particularly as a gestational parent or through surrogacy, the current standard guidance of fertility counseling for individuals on testosterone (T) lacks clarity. At this time, individuals are typically recommended to undergo fertility preservation or stop treatment, associating T-therapy with a loss of fertility; however, there is an absence of consistent information regarding the true fertility potential for transgender and gender-diverse adults and adolescents. This review evaluates recent studies that utilize animal models of T-GAHT to relate to findings from clinical studies, with a more specific focus on fertility. Relevant literature based on murine models in post- and pre-pubertal populations has suggested reversibility of the impacts of T-GAHT, alone or following gonadotropin-releasing hormone agonist (GnRHa), on reproduction. These studies reported changes in clitoral area and ovarian morphology, including corpora lutea, follicle counts, and ovarian weights from T-treated mice. Future studies should aim to determine the impact of the duration of T-treatment and cessation on fertility outcomes, as well as establish animal models that are clinically representative of these outcomes with respect to gender diverse populations.

Oocyte cryopreservation and reciprocal in vitro fertilization in a transgender man on long term testosterone gender-affirming hormone therapy: a case report

Objective

To report a successful case of oocyte cryopreservation and subsequent in vitro fertilization (IVF) in a transgender male receiving continued testosterone gender-affirming hormone therapy, followed by reciprocal embryo transfer (ET).

Design

A case report of a rare case of fertility preservation in a transgender man with concomitant use of testosterone therapy for 4 years before and during ovarian stimulation.

Setting

Private fertility clinic with university affiliation.

Patients

A 26-year-old transgender man undergoing oocyte cryopreservation before gender-affirming surgery.

Interventions

Fertility preservation using oocyte cryopreservation and IVF with reciprocal fresh ET into a cisfemale partner.

Main Outcome Measures

Successful oocyte cryopreservation, oocyte thawing, and reciprocal IVF cycle.

Results

Oocyte cryopreservation of 29 mature oocytes. Sixteen mature oocytes survived the thaw, and 12 were fertilized with intracytoplasmic sperm injection. A fresh ET of an advanced blastocyst resulted in a clinical pregnancy and live birth.

Conclusions

Fertility preservation with oocyte cryopreservation or IVF with embryo cryopreservation is feasible for patients on continued long-term testosterone gender-affirming therapy. Future studies on egg quality and reproductive outcomes are required. Our case report demonstrates a promising outcome in this patient population.

Fertility treatment outcomes in transgender men with a history of testosterone therapy

Objective

To evaluate fertility treatment outcomes among transgender (TG) men with a history of gender-affirming hormone therapy with exogenous testosterone.

Design

Descriptive, retrospective cohort study.

Patients

Transgender men with a history of gender-affirming hormone therapy with exogenous testosterone underwent fertility treatments, including embryo cryopreservation, in vitro fertilization (IVF), co-IVF, oocyte cryopreservation, and intrauterine insemination (IUI), between 2013 and 2021.

Intervention

Gender-affirming hormone therapy with testosterone.

Main Outcome Measures

Live births (LBs), number of frozen embryos, and number of frozen oocytes. Other outcome measures included total gonadotropin used, peak estradiol levels, oocytes retrieved, oocyte maturity rate, fertilization rate, and embryo grade.

Results

A total of 77 TG men self-presented or were referred to care at a single academic fertility center, of which 46 (59.7%) TG men underwent fertility preservation and/or family-building counseling, with 16 (20.8%) patients proceeding to fertility treatment. Of those patients who underwent treatment, 11 (68.8%) had a history of gender-affirming hormone therapy with exogenous testosterone use. Cohort 1 included IVF (n = 1), co-IVF (n = 1), embryo cryopreservation (n = 2), cohort 2 included oocyte cryopreservation (n = 4), and cohort 3 included IUI (n = 3). In cohort 1, both the patients who underwent IVF and the patients who underwent co-IVF achieved LBs. All embryo cryopreservation cycles froze three or more embryos. In cohort 2, the average number of frozen mature oocytes was 19.3 ± 16.2 (range 6-43). All patients who underwent IUI cycles achieved LB.

Conclusion

In this study, no correlation existed between patient age, time on or off gender-affirming hormone therapy with exogenous testosterone, total gonadotropin used, and number of oocytes retrieved. All patients who completed IVF or embryo cryopreservation produced high-quality blastocytes, and this is the first study to show successful IUI cycles in patients with a history of gender-affirming hormone therapy with exogenous testosterone. This study demonstrates that TG men who have used gender-affirming hormone therapy previously can successfully undergo fertility treatments to attain oocyte and embryo cryopreservation, pregnancy, and LBs.

Clinical management of transgender and non-binary patients in the fertility preservation service: Current evidence

Background: Transgender and non-binary individuals face unique challenges when it comes to fertility preservation (FP). Objective: Despite the growing prevalence of gender dysphoria (GD) and gender transitioning, there is a lack of clear guidelines and consensus on the management of these patients in the FP setting. Clinicians and institutions providing FP services should ensure that they are aware of the needs and circumstances of this underrepresented group of patients and offer them accurate and evidence-based information when counseling and tailoring their FP treatment. Materials and methods: For this scoping review, three major search engines were used. Including Embase, Epistemonikos, Google Scholar, MEDLINE and PubMed. Sources of grey literature were also explored (ResearchGate and Web of Science). The combination of only two keywords [transgender] AND [fertility preservation] was used up to May 2023. Results: The available evidence on clinical management and FP outcomes in transgender patients is limited and mainly originates from case reports or small case series. The main limitation of current FP services for transgender and non-binary individuals is the lack of scientific evidence regarding their care. Discussion: Overall, FP in transgender patients requires individualized and realistic plans, and psychological counseling should be offered. This review aims to provide the latest evidence coming from original studies to facilitate proper counseling and fertility management for these individuals. Conclusions: Inclusive health systems that provide comprehensive reproductive health care to transgender individuals can help them make informed decisions about FP and improve their quality of life. Future research is needed to establish more robust evidence-based guidelines for the management of transgender and non-binary individuals in the FP setting.

Outcomes of oocyte vitrification in trans masculine individuals

RESEARCH QUESTION

What are the outcomes and experiences of oocyte vitrification treatment in trans masculine individuals (TMI) before and after testosterone use?

DESIGN

This retrospective cohort study was conducted at the Amsterdam UMC in the Netherlands between January 2017 and June 2021. The TMI who had completed an oocyte vitrification treatment were consecutively approached for participation. Informed consent was provided by 24 individuals. Participants (n = 7) who initiated testosterone therapy were advised to stop 3 months before stimulation. Demographic characteristics and oocyte vitrification treatment data were retrieved from medical records. Evaluation of the treatment was collected via an online questionnaire.

RESULTS

The median age of participants was 22.3 years (interquartile range 21.1-26.0) and mean body mass index was 23.0 kg/m2 (SD 3.2). After ovarian hyperstimulation, a mean of 20 oocytes (SD 7) were retrieved and a mean of 17 oocytes (SD 6) could be vitrified. Aside from a lower cumulative FSH dose, there were no significant differences between the prior testosterone users and testosterone naïve TMI. The overall satisfaction of oocyte vitrification treatment in participants was high. Hormone injections were considered the most strenuous part of treatment by 29% of participants, closely followed by oocyte retrieval (25%).

CONCLUSIONS

No difference in response to ovarian stimulation was found for oocyte vitrification treatment between the prior testosterone users and testosterone naïve TMI. The questionnaire identified hormone injections as the most burdensome aspect of oocyte vitrification treatment. This information can be used to improve gender sensitive fertility counselling and fertility treatment strategies.

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.

Timing of testosterone discontinuation and assisted reproductive technology outcomes in transgender patients: a cohort study

Objective

To determine if there is an association between the timing of testosterone discontinuation and assisted reproductive technology (ART) outcomes.

Design

Retrospectivse cohort study.

Setting

Single academic center.

Patients

We included consecutive transgender patients seeking fertility preservation between October 2019 and April 2021. Patients who identified as transgender on androgens for >1 month on presentation were included.

Interventions

None.

Main outcome measures

A linear regression model was used to evaluate the effect of testosterone discontinuation duration on the number of mature oocytes retrieved.

Results

Eighteen patients (mean age 27.7 [SD 5.2] years, mean body mass index 27.3 [SD 4.6] kg/m², mean antimüllerian hormone 27.2 [SD 11.8], median antral follicle count 20 [interquartile range (IQR) 14-32]) were included in the analysis. No patient underwent transition-related surgery (eg, oophorectomy, hysterectomy). None of the patients were previously pregnant. Mean time o,n testosterone was 44 (SD 29.6) months. The median time off testosterone until the start of ovarian stimulation was 7.7 weeks (IQR 4.3-20.7). All patients underwent oocyte cryopreservation except one who had embryo cryopreservation. The median total number of oocytes was 11 (IQR 7-14). The median number of mature oocytes was 7.5 (IQR 5-12) oocytes. The univariate regression model evaluating the duration of time off testosterone before ART demonstrated no significant association with the outcome of mature oocytes (regression coefficient, 0.19; 95% confidence interval, -0.13 to 0.50).

Conclusion

In a retrospective analysis of transgender patients recently on testosterone undergoing ART, no association was detected between the timing of testosterone cessation and the number of mature oocytes.

Gender-affirming hormonal therapy for transgender and gender-diverse people-A narrative review

As the number of transgender and gender-diverse (TGD) people accessing gender-affirming care increases, the need for healthcare professionals (HCPs) providing gender-affirming hormonal therapy (GAHT) also increases. This chapter provides an overview of the HCPs interested in getting involved in providing GAHT.

Family Building Perspectives of Assigned Female at Birth Transgender and Gender Diverse Adolescents Seeking Testosterone Gender-Affirming Hormone Therapy

Purpose: The purpose of this study was to assess the future family building desires of assigned female at birth (AFAB) transgender and gender diverse (TGD) adolescents initiating hormone therapy, and to characterize the individuals interested in adoption. Methods: This was a retrospective chart review of AFAB TGD adolescents ages 15-17 years old initiating testosterone gender-affirming hormone therapy between 2010 and 2019, analyzing interest in adoption, demographics, and gender-affirming care. Results: Of 195 AFAB TGD adolescents asked about family planning goals, 58% (n = 113) indicated desire for adoption in their future, and 13.3% (n = 26) had no desire for children. There was no difference between those who did and did not want to adopt in terms of age at time of first visit (p = 0.22), or race distribution (p = 0.45); however, straight-identified patients were more likely to desire adoption (p = 0.02) than people with other sexual orientations. Fifty-nine percent (n = 110) of those who did not have a history of adoption and/or experience with the child welfare system desired adoption, compared with 22% (n = 2) of those with a history (odds ratio, 5.14; 95% confidence interval, 1.04-25.39; p = 0.05). Conclusion: Some AFAB TGD adolescents endorse adoption as their desired pathway to parenthood. Clinicians should be sensitive to the complexities of parenthood desires of AFAB TGD patients and have resources to direct patients to more information. Further research is needed to better understand why many AFAB TGD adolescents desire adoption, how this changes with age, and the barriers they face in achieving their goals.

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.

Fertility Preservation for Transgender Males: Counseling and Timing of Treatment

Fertility-preservation counseling in the transgender patient population is recommended by multiple organizations, including the American Society for Reproductive Medicine, the World Professional Association for Transgender Health, and the Endocrine Society. The optimal time to pursue fertility preservation has not been established, and data on potential effects of testosterone therapy on future reproductive potential are limited. This Current Commentary seeks to elucidate the most appropriate time to perform oocyte cryopreservation in relation to time on and off testosterone therapy, age of the individual, and emotional effect of treatment. Although there have been multiple studies that have demonstrated successful oocyte cryopreservation regardless of testosterone exposure, the data on live-birth rates after oocyte cryopreservation are limited. Moreover, the process of oocyte cryopreservation may have a significant negative emotional effect on the transgender male given the feminizing effects of gonadotropin stimulation, as well as the invasiveness of pelvic ultrasonograms and the oocyte-retrieval procedure. With our review, we demonstrate that a comprehensive, individualized approach to fertility-preservation counseling and timing to pursue treatment are essential. Postponing fertility-preservation procedures until patients have reached early adulthood might be considered to avoid the potential effect on mental health, without compromising outcomes.

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.