From the Journals

Semen cryopreservation viable for young transgender patients in small study

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Fertility counseling, access imperative for young transgender patients

The lack of long-term data on various gender-affirming medical interventions, particularly hormone therapies, for transgender adolescents and young adults has led professional medical organizations to recommend patients receive fertility counseling before beginning any such therapies.

Yet few data exist on fertility preservation either. The study by Barnard et al. is the first to examine semen cryopreservation outcomes in adolescents and young adults assigned male at birth and asserting a female gender identity.

“There is often urgency to start medical affirming interventions (MAI) among transgender and gender-diverse adolescents and young adults (TGD-AYA) due to gender dysphoria and related psychological sequelae,” wrote Jason Rafferty, MD, MPH, in an accompanying editorial. “However, starting MAI immediately and delaying fertility services may lead to increased overall morbidity for some patients.”

Although multiple professional organizations recommend fertility counseling before MAI initiation, many transgender patients are not following this advice. Dr. Rafferty noted one study found only 20% of TGD-AYA discussed fertility with their physicians before beginning MAI, and only 13% discussed possible effects of MAI on fertility – yet 60% wanted to learn more.

“Barnard et al. review data suggesting TGD-AYA have low interest in fertility services, but many TGD-AYA questioned whether this may later change,” Dr. Rafferty wrote. “After starting MAIs, TGD-AYA report being more emotionally capable of considering future parenting because of increasing comfort with their bodies and romantic relationships.”

Various barriers also exist for TGD-AYA interested in fertility services, such as cost, lack of insurance coverage, low availability of services, increased dysphoria from the procedures, stereotypes, stigma, and interest in starting MAI as soon as possible.

“Under a reproductive justice framework, autonomy around family planning is a right that should not be limited by structural or systemic barriers,” Dr. Rafferty wrote. “Overall, there is a clinical and ethical imperative to better understand and provide access to fertility services for TGD-AYA.”

Jason Rafferty, MD, MPH, is a pediatrician and child psychiatrist who practices at the gender and sexuality clinic in Riverside and at the Adolescent Healthcare Center at Hasbro Children’s Hospital in Providence, R.I. His comments are summarized from an accompanying editorial (Pediatrics 2019 Aug 5. doi: 10.1542/peds.2019-2000).


 

FROM PEDIATRICS

Cryopreserving semen is a feasible option for preserving the fertility of adolescents and young adults who were assigned male at birth and are beginning or have already begun gender-affirming treatment as transgender women, according to results of a small retrospective cohort study.

The lack of data on this topic, however, makes it difficult to determine how long an individual must be off gender-affirming therapy before spermatogenesis resumes, if it resumes, and what the long-term effects of gender-affirming therapy are.

“This information is critical to address as part of a multidisciplinary fertility discussion with youth and their guardians so that an informed decision can be made regarding fertility preservation use,” wrote Emily P. Barnard, DO, of UPMC Magee-Womens Hospital in Pittsburgh and her associates.

The researchers retrospectively collected data on transgender patients who sought fertility preservation between 2015 and 2018.

The 11 white transgender women (sex assigned male at birth) who followed up on adolescent medicine or pediatric endocrinology referrals for fertility preservation received their consultations between ages 16 and 24, with 19 years having been the median age at which they occurred. Gender dysphoria onset happened at a median age of 12 for the patients, who were evaluated for it at a median age of 17.

All but one patient submitted at least one semen sample, and eight ultimately cryopreserved their semen.

The eight samples from gender-affirming therapy–naive patients had abnormal morphology, with the median morphology having been 6% versus the normal range of greater than 13.0%. Otherwise, the samples collected were normal, but the authors noted that established semen analysis parameters don’t exist for adolescents and young adults.

All eight patients who had their semen cryopreserved, began gonadotropin-releasing hormone (GnRH) agonist therapy after cryopreservation, and four of those patients concurrently began taking estradiol.

One patient had already been taking intramuscular leuprolide acetate every 6 months and discontinued it to attempt fertility preservation. Spermatogenesis returned after 5 months of azoospermia, albeit with abnormal morphology (9%).

Another patient had been taking spironolactone and estradiol for 26 months before ceasing therapy to attempt fertility preservation. She remained azoospermic 4 months after stopping therapy and then moved forward with an orchiectomy.

“For many transgender patients, the potential need to discontinue GnRH agonist or gender-affirming therapy to allow for resumption of spermatogenesis may be a significant barrier to pursuing fertility preservation because cessation of therapy may result in exacerbation of gender dysphoria and progression of undesired male secondary sex characteristics,” the researchers wrote. “For individuals for whom this risk is not acceptable or if azoospermia is noted on semen analysis, there are several alternate options, including electroejaculation, testicular sperm extraction, and testicular tissue cryopreservation,” they continued. Electroejaculation with a transrectal probe is an option particularly for those who cannot masturbate or feel uncomfortable doing so, the authors explained.

For those who have not previously received gender-affirming therapy, the fertility preservation “process can be completed quickly, with collections occurring every 2 to 3 days to preserve several samples before initiating GnRH agonist or gender-affirming therapy,” they concluded.

SOURCE: Barnard EP et al. Pediatrics. 2019 Aug 5. doi: 10.1542/peds.2018-3943.

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