Fertility preservation discussions, referral and follow-up in male-to-female and female-to-male adolescent transgender patients

The number of patients seeking transgender healthcare is growing, and there is a potential impact of gender-affirming therapies on fertility. The use of fertility preservation (FP), particularly among transgender adolescents, has been limited. We aimed to examine differences in FP counselling, referral and utilisation between male-to-female (MtF) and female-to-male (FtM) transgender adolescents. A retrospective review of the medical records of patients ages 12-17 seen at an academic medical centre between 2012 and 2017 with a diagnosis of gender dysphoria was conducted. A total of 22 MtF and 45 FtM adolescents were included. The counselling on the potential fertility impact of gender-affirming therapy was documented in 55%, and of those counselled, 73% were counselled before receiving medication. There was no significant difference between the timing of counselling for MtF versus FtM adolescents. Of patients with documented reproductive wishes, 77% reported either desire for adopted children or no desire for biological children. Among patients offered FP referral, 2 (22.2%) MtF and 3 (12.5%) FtM patients accepted; both MtF patients cryopreserved sperm. While most adolescents were counselled on the fertility impact of gender-affirming therapy, there is room for improvement as 45% of patients had no documented counselling. The rate of transgender adolescents pursuing FP consultation and gamete cryopreservation was low, consistent with prior studies in this population.

Polish Female Cancer Survivors' Experiences Related to Fertility Preservation Procedures

Purpose: The aim of the study was to assess the experience of Polish female cancer patients related to fertility preservation (FP) after gonadotoxic treatment. Methods: A cross-sectional study was performed among young women, who were diagnosed with a neoplasm. The questionnaire was distributed via the Internet. Results: The study group consisted of 299 women. Most of them had breast cancer (34%) or Hodgkin lymphoma (20%). The most popular treatment regimen was a combination of surgery, chemotherapy, and radiation (30%). Almost 78% of study participants underwent potentially gonadotoxic treatment. Fifty-seven percent of study participants admitted that oncologist had not informed them about FP methods, while only 19% were encouraged to visit fertility specialists. Seventeen percent of women decided to preserve fertility before malignancy treatment, 11.8% of women cryopreserved oocytes, 16% cryopreserved embryos, 16% cryopreserved ovarian tissue and 55% had ovarian suppression. Conclusion: The access to fertility counseling in Poland is limited. Emphasis should be placed on the coordination between cancer treatment centers and reproductive specialists.

Sperm parameters in Israeli transgender women before and after cryopreservation

BACKGROUND

The application of fertility preservation, initially intended for oncological patients prior to gonadotoxic treatment, has extended in recent years to transgender and gender-non-conforming individuals undergoing therapy for gender compatibility.

OBJECTIVES

To examine semen quality and survival in transgender women pursuing semen cryopreservation in the presence or absence of gender-affirming hormonal medication.

MATERIALS AND METHODS

In this retrospective cohort study, we reviewed data of 74 consecutive transgender women presenting for semen cryopreservation at a single center between 2000 and 2019. Semen parameters before and after cryopreservation were compared to a control group composed of 100 consecutive sperm bank donor candidates. A subgroup analysis of subjects who had used gender-affirming hormonal treatment was also performed.

RESULTS

Compared to the control group, transgender women had lower total sperm count (144.0 vs. 54.5 million, respectively, p < 0.001), lower sperm motility percentage (65.0% vs. 51.0%, respectively, p < 0.001), and lower total motile sperm count (94.0 vs. 27.0 million, respectively, p < 0.001). Values were further decreased in transgender women who had received hormonal treatment before sperm cryopreservation. Post-thawing motility rate remained lower in the transgender group compared to the control group (20.0% vs. 45.0%, respectively, p < 0.001), and the total motile count remained lower as well (2.7 vs. 9.0 million, respectively, p < 0.001). Following sperm cryopreservation, the post-thaw decreases in total motile sperm count were higher in the transgender group compared with the control group (91.5% vs. 90.0%). Further subdivision in the transgender group showed that the decrease in total motile sperm count was lower for transgender women who did not use gender-affirming hormonal treatment compared to those who did (-89.7% vs. -92.6%, respectively, p < 0.01).

DISCUSSION AND CONCLUSION

Sperm parameters in transgender women are poor compared to candidates for sperm donation representing the general population. Specimens collected after discontinuation of gender-affirming hormone treatments were further impaired. Moreover, post-thawing sperm total motile count, motility, and overall sperm survival were reduced in transgender women.

Effect of Sperm Cryopreservation on miRNA Expression and Early Embryonic Development

Although sperm preservation is a common means of personal fertility preservation, its effects on embryonic development potential need further investigation. The purpose of this study was to identify key microRNA (miRNA) in cryopreserved sperm and determine the changes of these miRNAs and their target genes during embryonic development using cryopreserved sperm. Moreover, the embryonic development potential of cryopreserved sperm was estimated in assisted reproductive technology (ART), where key miRNAs and target genes were validated in sperm and subsequent embryos. Clinical data of embryonic development from cryopreserved sperm indicated a significant decrease in fertilization rate in both in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cases, as well as a reduction in blastocyst formation rate in ICSI cases. Meanwhile there was a significant increase in blocked embryo ratio of Day1, Day2, and Day3.5 embryos when frozen-thawed mouse sperm was used, compared with fresh mouse sperm, suggesting a potential negative effect of sperm cryopreservation on embryonic development. From frozen-thawed and fresh sperm in humans and mice, respectively, 21 and 95 differentially expressed miRNAs (DEmiRs) were detected. miR-148b-3p were downregulated in both human and mouse frozen-thawed sperm and were also decreased in embryos after fertilization using cryopreserved sperm. Target genes of miR-148b-3p, Pten, was identified in mouse embryos using quantitative real-time PCR (qRT-PCR) and Western blot (WB). In addition, common characters of cryopreservation of mouse oocytes compared with sperm were also detected; downregulation of miR-148b-3p was also confirmed in cryopreserved oocytes. In summary, our study suggested that cryopreservation of sperm could change the expression of miRNAs, especially the miR-148b-3p across humans and mice, and may further affect fertilization and embryo development by increasing the expression of Pten. Moreover, downregulation of miR-148b-3p induced by cryopreservation was conserved in mouse gametes.

"Double Frozen Transfer" Could Influence the Perinatal and Children's Growth: A Nested Case-Control Study of 6705 Live Birth Cycles

OBJECTIVE

This study aims to evaluate neonatal and children growth outcomes of cryotransfer of embryos developed from frozen gametes [double frozen transfer (DFT)].

METHODS

This nested case-control study included 6,705 women who had a singleton live birth after embryo transfer at the Center for Reproductive Medicine, Shandong University, from 2008 to 2020. Of these, 745 women underwent frozen embryo transfer (FET) using embryos developed from frozen gametes (DFT). Propensity score methodology was used to balance the two groups by maternal age and body mass index (BMI) before evaluating outcomes. After age and BMI were matched using the propensity score methodology in a ratio of 1:4, the control groups enrolled 2,980 women who underwent fresh embryo transfer (ET) and 2,980 women underwent FET from fresh gametes. The children born were followed to at least 5 years of age, and some were followed up to 10 years. Neonatal outcomes and childhood growth measurements were compared among the three groups.

RESULTS

The average birth weight of the DFT group (3,462 g) was significantly higher than the FET group (3,458 g) and ET group (3,412 g). The rate of large for gestational age (LGA) babies in the DFT and FET group was higher than that for the ET group (30.9% vs. 24.8%; 29.4% vs. 24.8%, respectively). After adjusting for different confounder combinations in the three models, the birth weight and risk of LGA in the DFT and FET groups were still higher than in the ET group, and the values group of P for trend in the models were significant. In multiple linear regression analysis of the children's development, the height Z-score of children born from the DFT and FET group was higher than that for children from the ET group (β = 0.21, 95% CI 0.07-0.35; b = 0.17, 95% CI 0.05-0.28, respectively). However, childhood growth measurements including body weight Z-score and BMI Z-score were not significantly different among the three groups. In addition, the proportion of male children born from DET was higher than that from ET.

CONCLUSIONS

There is an increased risk of LGA babies associated with pregnancies conceived from DFT. Children are inclined to be taller in the future in this group than after FET. The related etiology and pathophysiology mechanisms still need to be revealed. In the future, well-designed, observational studies with in-depth collection of patients' characteristics may shed more light on this issue.

Factors Affecting Fertility Decision-Making Among Transgender Adolescents and Young Adults

PURPOSE

This study aimed to identify factors affecting transgender adolescents' and young adults' (AYA) decisions to pursue fertility preservation (FP).

METHODS

Participants completed a semistructured interview between December 2016 and June 2017 to inform improvements in fertility counseling and the development of a fertility decision aid targeted to transgender youth. Interviews included open-ended questions within the following domains: (1) gender-affirming medical care received, (2) knowledge of gender-affirming hormone effects on fertility and FP options, (3) FP decision-making, and (4) how, when, and what information AYA prefer to receive regarding FP. The interviews were analyzed thematically.

RESULTS

Eighteen transgender AYA (ages 15-24) participated (60% participation rate). The majority was White (61%) and assigned female at birth (67%). Half received specialized FP counseling (50%). Few of the transgender AYA pursued FP (33%). Five key themes reflecting factors affecting transgender AYA's FP decision-making were identified: (1) future parenthood desires, (2) individual experiences of gender dysphoria, (3) family values around biological parenthood, (4) financial considerations, and (5) fertility information provision.

CONCLUSIONS

Transgender AYA consider numerous factors in deciding whether to pursue FP. Although individual desires for and family values around biological parenthood influenced whether AYA pursued specialized FP counseling, individual experiences of gender dysphoria and costs of FP were barriers. AYA also identified shortcomings in fertility counseling with providers, highlighting the need to establish standardized counseling protocols and develop patient decision aids.

Fertility preservation: should we reconsider the terminology?

The term 'fertility preservation' embraces techniques that are actually mostly based on gamete and gonadal tissue cryopreservation. While the efficiency of these techniques in terms of live births remains difficult to establish, it is remarkable that this ambiguous terminology is routinely used and seems currently well accepted. In order to limit false hopes about the real chances of truly preserving fertility, our medical community should discuss qualifying the term 'fertility preservation'. 'Gamete or gonadal tissue cryopreservation' could appear as a more unambiguous and realistic term. However, it probably captures only a segment of a more global 'fertility preservation' process. Discussing how and when to use which terminology, and even finding a more realistic and unifying term, should be further explored.