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Why fertility preservation rates of transgender men are much lower than those of transgender women
Abstract
Research question
What are the fertility preservation (FP) rates of transgender women and transgender men, and which factors affect their decision making?
Design
This prospective study included 97 transgender women and 91 transgender men referred to the Gender Clinic of our medical center's Endocrinology Institute and to the Gan Meir Community Health Care Center. The responders completed a 28-item questionnaire during 2018.
Results
Most of the transgender women and transgender men wished to parent a child (67.4% and 61.9%, respectively, P = 0.447), but only 40.4% of the transgender women and 5.8% of the transgender men utilized FP (P < 0.001). The main reasons for not pursuing FP were unwillingness to postpone gender-affirming treatment (58.8% and 74%, respectively, P = 0.076), preference to adopt a child (58.8% and 60.9%, respectively, P = 0.818), and cost (44.9% and 60.9%, respectively, P = 0.086). Factors related to the FP process itself were specifically chosen by transgender men compared to transgender women as the reason for not pursuing FP, including distress from the FP technique (60.3% versus 29.3%, respectively, P = 0.006), fear of gender dysphoria due to hormonal treatment (63.5% versus 28.3%, P = 0.002), and concern over the medical staff's attitude (44% versus 19%, P = 0.027).
Conclusions
FP rates were considerably lower among transgender men compared to transgender women, highly related to the FP process itself. Finding ways to overcome the obstacles confronted by transgender individuals, especially transgender men, will enhance their future biological parenting.
... One study reported that 67.4% of transgender women and 61.6% of transgender men had a desire to parent a child, with 50% and 37%, respectively, desiring a biological one. 8 Thus, fertility counseling early in the transition process can aid in attaining these goals. Health care providers should be sure to discuss all options with patients prior to hormone therapy or surgical intervention. ...
... Health care providers should be sure to discuss all options with patients prior to hormone therapy or surgical intervention. 8 Transgender men can pursue fertility preservation or carry a pregnancy to term before and after gender affirming therapy. However, the effects of prolonged testosterone therapy on pregnancy and fetal outcomes remain unclear. ...
... The European Society of Human Reproduction and Embryology recommends providers do so prior to beginning hormone therapy due to the impacts of testosterone on embryo development and estrogen on sperm quality. 8,12,18 Having these discussions prior to commencement of hormone therapy can also prevent the discontinuation of transitional hormones, which can be emotionally damaging and exacerbate gender dysphoria. 12 Even with insurance coverage, fertility preservation options remain expensive, so providers should be sure to explain all the options to patients. ...
Family planning is critical to the sexual and reproductive health of all patients. For transgender individuals, using gender-preferred modalities for conception and prevention can minimize gender incongruence and dysphoria. Currently, the literature describes several pregnancy options including natural conception, gamete cryopreservation, in vitro fertilization, and uterine transplantation. Prevention methods remain similar to those for cisgender patients such as oral contraception, intrauterine devices, condoms, and various surgical procedures. However, great emphasis lies on choosing a method that best supports the chosen gender identity of the patient. This review supports oocyte and sperm cryopreservation as the preferred method for pregnancy and finds consensus with the literature that there is no best method for prevention. As such, physicians should prioritize early discussions with patients and work closely to use modalities that fit each patient’s needs and expectations. As the body of literature on LGBTQ+ health continues to grow, this review will help to expand the knowledge around family planning for transgender patients.
... Fertility preservation rates are higher among transgender women, compared to transgender men (Alpern et al., 2022). Concerns regarding the fertility preservation process itself, fear of gender dysphoria caused by hormonal treatment and concerns regarding the attitude of medical staff were more likely to dissuade transgender men from fertility preservation when compared with transgender women (Alpern et al., 2022). ...
... Fertility preservation rates are higher among transgender women, compared to transgender men (Alpern et al., 2022). Concerns regarding the fertility preservation process itself, fear of gender dysphoria caused by hormonal treatment and concerns regarding the attitude of medical staff were more likely to dissuade transgender men from fertility preservation when compared with transgender women (Alpern et al., 2022). Higher fertility preservation rates among transgender women than transgender men have also been demonstrated by others; interestingly, the opposite trend was seen in transgender adolescents . ...
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.
... Same-sex male couples (and indeed single men or women, who may or may not be gay), while still facing some sociocultural obstacles to becoming families, have been shown to have similar drivers to pursue (biological) parenthood as heterosexual couples who want families (Carone et al., 2017;Hemalal et al., 2021;Smietana, 2018) and there has been a significant increase in the numbers of same-sex male couples pursuing parenthood via assisted reproduction and surrogacy (Dar et al., 2015;Golombok et al., 2018;Perkins et al., 2016). Recent studies have also shown that many transgender men and women have strong desires to become parents, but also that uptake of fertility preservation is low, particularly in transgender men (Alpern et al., 2022;Amir et al., 2020). ...
Research question:
What implications for policy and practice can be derived from outcomes and trends observed across 8 years of a surrogacy programme in two UK-regulated IVF centres (London, Cardiff)?
Design:
Retrospective cohort study analysing surrogacy treatments undertaken between 2014 and September 2021.
Results:
Surrogacy continues to rise in popularity in the UK despite the inability of those supporting safe and professional practice to advertise to recruit surrogates. In two IVF centres regulated by the Human Fertilisation and Embryology Authority (HFEA), both the number of surrogacy treatments and the proportion of those undertaken on behalf of same-sex male intended parents increased year on year in the period studied. From a cohort of 108 surrogates, 71 babies were born to 61 surrogates (with five pregnancies ongoing) by February 2022. No statistically significant difference in live birth rates (LBR) was observed between the heterosexual couples and same-sex male couples. Sample sizes of single and transgender intended parents were too small (n < 5) to compare. The use of vitrified oocytes in surrogacy treatments has increased year on year, while fresh oocyte use has declined since peaking in 2019. There was no significant difference in LBR between fresh and vitrified oocyte usage across the cohort.
Conclusions:
The number of surrogacy treatments steadily increased, with clear evidence that the proportion of same-sex male couples accessing surrogacy is a major contributor to this growth. Vitrified/warmed oocyte use now outstrips the use of fresh oocytes in the surrogacy treatment cycles studied here. The results represent a strong basis for supporting the liberalization of regulatory reform expected to be introduced in the UK later in 2022.
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.
Most of transgender people plan to have a family but their fertility may be affected by gender affirmation. Hormone therapy can permanently affect gamete production, especially in trans women. Sex reassignment surgery leads to permanent sterility. In France, networks of health professionals have been organized and recommend access to fertility preservation for trans people. However, gamete collection is often difficult due to hormonal incongruence for trans women or to the invasive nature of the procedure for trans men. Future studies are required to assess the use of self-preserved gametes by trans people.
Objectives
To describe family planning and fertility counseling perspectives of reproductive-age gender diverse adults and youth pursuing gender affirming hormone therapy.
Methods
This was a cross sectional survey study of gender diverse adults and youth no older than 55 years who for gender affirming hormone therapy. The primary outcomes of interest were parental desire and priorities for fertility preservation.
Results
57 individuals (46 adults and 11 youths) completed the survey; 51% were transgender women, 35% were transgender men, and 14% identified as non-binary. 32 participants expressed interest in (n=15, 26%) or uncertainty about (n=18, 32%) future parenthood. 48% of participants had considered gamete cryopreservation, but only 7% each previously completed or planned to pursue this fertility option; 67% cited cost as a barrier. Participants with interest in or uncertainty about future parenthood were more likely to consider cryopreservation (p<.001) or stopping hormones for fertility preservation (p<.001). 58% of respondents reported discussing fertility preservation with a health care provider with lower rates among youth participants (p = 0.017). From a family planning perspective, 58% of respondents described counseling as adequate; 23% described it as inadequate and 19% reported not receiving any counseling. Participants who endorsed strong or uncertain parental desire were more likely to report inadequate counseling (p=0.016).
Conclusions
Gender diverse individuals interested in or undecided about future parenthood were more likely to consider cryopreservation and report inadequate family planning counseling. Therefore, current counseling practices may be insufficient and referral to a fertility specialist should be considered.
Résumé
L’évolution des techniques médicales ainsi que les changements législatifs permettent actuellement de proposer des stratégies de préservation de la fertilité dans le contexte de transidentité. Lors des parcours de transition « female to male », dit FtM, l’androgénothérapie a un impact sur la fonction gonadique puisqu’elle induit généralement un blocage de l’ovulation avec aménorrhée. Bien que cet effet soit réversible à l’arrêt du traitement, les éventuels effets à long terme du traitement par testostérone sur la fertilité future, voire sur la santé des enfants à naître, ne sont pas connus. De plus, les chirurgies de transition compromettent définitivement la possibilité de grossesse lorsqu’elles comprennent une annexectomie bilatérale et/ou une hystérectomie. Pourtant, bien qu’il ait été longtemps ignoré ou peu exprimé, le désir de parentalité est présent chez les hommes transgenres. Les options de préservation de la fertilité dans le cadre d’une transition FtM reposent sur la cryoconservation d’ovocytes ou de tissu ovarien. Cette revue a pour objectif de réaliser un état des lieux de la littérature concernant la préservation de la fertilité des hommes transgenres. Même si les séries restent limitées, l’augmentation du nombre d’articles récemment publiés témoigne de l’intérêt porté à l’amélioration de la prise en charge des questions de fertilité chez les hommes transgenres.
Transgender patients often desire to have biological children. However, their reproductive potential is often negatively impacted by gender affirming surgery (GAS) such as gender confirmation surgery (bottom surgery) and medical hormone therapy. Therefore, counselling patients on fertility preservation options before initiating gender-affirming treatments is prudent to avoid reducing their reproductive potential. A systematic review of English, Spanish, Chinese, French and Turkish languages from 2000 to December 23rd, 2019, using the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines, was conducted. The search strategy was designed and conducted by an experienced librarian with input from the study's principle investigator. Fifteen articles that report outcomes of fertility preservation options in transgenders were included. Eight articles described options for transgender women, six reported options for transgender men and one included both transgender women and transgender men. Semen cryopreservation and oocyte cryopreservation are the most common and available methods for fertility preservation in transgenders. Physician awareness of fertility preservation options in transgender patients is crucial to ensure informed discussions regarding reproductive options in the early phase of transition.
Objective
To report a case of ovarian stimulation for the purposes of oocyte cryopreservation in a transgender man without cessation of long-term testosterone therapy
Design
Report of a unique case of fertility preservation through ovarian stimulation and oocyte cryopreservation in a transgender man who had been on testosterone therapy for 18 months prior to treatment. The patient elected to continue testosterone therapy throughout ovarian stimulation and oocyte retrieval. As of 2019 there have not been any published reports of patients undergoing oocyte cryopreservation while continuing long-term testosterone therapy.
Setting
Private fertility clinic with university affiliation
Patient
A 20-year-old transgender man undergoing oocyte cryopreservation prior to gonadectomy
Intervention
Fertility preservation through oocyte cryopreservation
Main Outcome Measure(s)
This patient had a robust response to ovarian gonadotropin stimulation. Leuprolide acetate was used for final oocyte maturation to minimize ovarian hyperstimulation syndrome risk.
Result(s)
Cryopreservation of 22 mature oocytes
Conclusion(s)
Cryopreservation of mature oocytes is possible for patients on continued long-term testosterone therapy. The impact of long-term testosterone therapy on markers of ovarian reserve, reproductive potential, and long-term reproductive outcomes have yet to be elucidated and further studies are needed in this area.
Background
Advances in biomedical technologies permit transgender individuals not only to achieve gender transition but also to experience parenthood. Little is known about this topic in Greece, which, although a traditionally conservative country, is changing at the legal level towards a greater recognition of transgender people’s rights. This study aimed to investigate transgender people’s attitudes towards having a child to whom they are genetically related and pursuing fertility treatments in Greece.
Methods
This is a prospective qualitative study conducted with adult individuals who identified as transgender men or transgender women between April 2019 and March 2020. Individual in-depth qualitative interviews were conducted with 12 participants. The interviews were carried out in person and were digitally recorded and transcribed verbatim. We performed a thematic analysis of the data.
Results
The thematic data analysis resulted in the identification of themes that represent key barriers to pursuing fertility preservation or the use of assisted reproductive technology. Six major themes were clearly present in the findings (lack of adequate information and counseling, worsening gender dysphoria, increased discrimination against transgender people due to the rise of extreme far-right populism, low parental self-efficacy, high costs, and a less-than-perfect legal framework). Moreover, diverse cases were examined, and minor themes, such as the symbolic value of the uterus and pregnancy, the relationship between the type of gender transition and willingness to pursue fertility treatments, and transgender people’s adherence to heteronormative patterns in the context of reproduction, were identified. Various reasons for transgender people’s differing degrees of desire for parenthood were identified.
Conclusion
Our findings demonstrated contextual factors as well as factors related to transgender people themselves as barriers to pursuing transgender parenthood. Most aspects of our findings are consistent with those of previous research. However, some aspects of our findings (regarding aggressive behaviors and economic instability) are specific to the context of Greece, which is characterized by the rise of extreme far-right populism due to the decade-long Greek economic crisis and a deeply conservative traditionalist background. In that regard, the participants highlighted the (perceived as) less-than-perfect Greek legislation on transgender people’s rights as a barrier to transgender (biological) parenthood.
Despite the burgeoning scholarship on transgender health and health care, the literature on transgender reproduction and reproductive medicine remains limited. In this narrative literature review, we examine recently published studies focused on the pregnancy and birth experiences of transgender men to provide an overview of the literature's major contributions and illuminate the gaps that exist within this research. Our review reveals that transgender men face substantial obstacles to achieving pregnancy and significant challenges during pregnancy and birth, which are informed by institutionalized cisnormativity embedded within medical norms and practices. This article demonstrates the importance of better understanding transgender men's reproductive health care needs in order to improve the quality of pregnancy-related health care delivery to this population. Our findings also provide insight for researchers, health care providers, and educators seeking to create and enhance gender-affirming medical education and training.
Purpose of Review
This review aims to update readers on recent evidence in order to counsel and guide clinical management of individuals with gender dysphoria seeking fertility preservation (FP).
Recent Findings
Relevant topics include a discussion of the consistent desire for children in transgender people despite a low utilization rate of FP services, animal models, and human histology depicting the effect of gender-affirming treatment (GAT) on the gonads, varied time for resumption of menses, and start of ovarian stimulation upon discontinuing testosterone (T) in transmen, feasible clinical and experimental options for FP in transgender males and females, worsening dysphoria, and recommended methods to mitigate symptoms, and lastly a short discussion of changes in legislation providing increased insurance coverage of medically indicated FP for transpatients.
Summary
FP is an important option for transgender patients who desire to retain the ability to become genetic parents. While controlled ovarian stimulation for oocyte or embryo cryopreservation is the standard-of-care for transmen, unique considerations must be made in this population. Recent literature has highlighted the ability of transmen to have viable oocytes and pregnancies despite a history of T use, suggesting that the window of genetic parentage does not close with the start of GAT. FP for transwomen requires ejaculation or extraction with sperm cryopreservation; options for prepubertal transwomen are only in nascent phases. Research is rapidly evolving though many questions remain unanswered. The harmonization of advances in assisted reproduction with legislation advocating for transgender rights will continue to reach new peaks in the coming years.
Objective
To study the feasibility of fertility preservation in a transgender male without an extended period of androgen cessation.
Design
Report of a seminal case of oocyte cryopreservation in a transgender man without stopping testosterone therapy before controlled ovarian stimulation. We performed a literature review, identifying 5 publications on oocyte cryopreservation outcomes in transgender men on testosterone.
Setting
A university-affiliated fertility clinic in Canada.
Patient(s)
A 28-year-old transgender man, taking testosterone for 3 years requesting oocyte cryopreservation before gender-affirming surgery. He desired to proceed without stopping testosterone. Pre-treatment AMH was 1.89 ng/mL. The patient’s consent was obtained for written publication.
Intervention(s)
Testosterone was stopped for only three doses (immediately prior to and during ovarian stimulation. A standard antagonist protocol was used with letrozole, to minimize estrogenic side effects.
Main Outcome Measure(s)
Number of oocytes retrieved and days off testosterone.
Result(s)
Thirteen oocytes were retrieved; eleven were mature and vitrified. The total time off testosterone was 24 days. In all prior publications, testosterone was stopped for 3-6 months.
Conclusion(s)
Transgender men have traditionally discontinued exogenous testosterone until the resumption of menses (up to 6 months). This is known to be distressing. This is the first published case demonstrating the feasibility of ovarian stimulation without prolonged testosterone cessation in a transgender man. Future studies with a larger sample size should be performed to confirm these findings. The short duration off testosterone may improve patient’s experiences, increase treatment acceptability, and decrease gender dysphoria for transgender men considering fertility preservation.
Objective
To update the “Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline,” published by the Endocrine Society in 2009.
Participants
The participants include an Endocrine Society–appointed task force of nine experts, a methodologist, and a medical writer.
Evidence
This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.
Consensus Process
Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines.
Conclusion
Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person’s genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person’s affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments—appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)—should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.
This Task Force document discusses ethical issues arising with requests for medically assisted reproduction from people in
what may be called ‘non-standard’ situations and relationships. The document stresses that categorically denying access to
any of these groups cannot be reconciled with a human rights perspective. If there are concerns about the implications of
assisted reproduction on the wellbeing of any of the persons involved, including the future child, a surrogate mother or the
applicants themselves, these concerns have to be considered in the light of the available scientific evidence. When doing
so it is important to avoid the use of double standards. More research is needed into the psychosocial implications of raising
children in non-standard situations, especially with regard to single women, male homosexual couples and transsexual people.
The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.
Purpose of review:
To synthesize recent literature to better understand parenting desires and challenges of transgender individuals as well as the impact of gender-affirming care on reproductive potential.
Recent findings:
Survey studies of transgender and nonbinary individuals demonstrate significant parenting interest, yet uptake in fertility preservation services remains low with potential for decisional regret. Masculinizing hormones have demonstrated variable effects on folliculogenesis and follicle distribution in the human ovary. In the mouse model, testosterone administration has demonstrated an increase in atretic late antral follicles without a reduction in primordial or total antral follicle counts and a preserved ability to respond to gonadotropin stimulation. Case series of transgender individuals undergoing oocyte or embryo cryopreservation are promising with outcomes similar to cisgender controls. Feminizing hormones have shown detrimental effects on sperm parameters at time of cryopreservation and spermatogenesis in orchiectomy samples with uncertainty regarding the reversibility of these changes.
Summary:
Current evidence demonstrates variable effects of gender-affirming hormones on ovarian and testicular function with potential for detrimental impact on an individual's reproductive potential. As many individuals initiate gender-affirming care prior to or during their reproductive years it is imperative that they receive thorough fertility preservation counseling and improved access to reproductive care services.
Objective
To characterize the patient and provider perspectives on cultural competence in lesbian, gay, bisexual, transgender, and queer (LGBTQ+) fertility care.
Design
Systematic review.
Setting
Not applicable.
Patient(s)
LGBTQ+ patients and their partners treated for fertility-related care; fertility providers who treat LGBTQ+ patients.
Intervention(s)
We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines of six databases: Medline-OVID, EMBASE, CINAHL, Cochrane Library, ClinicalTrials.Gov, and PsycInfo. Citations of full-text articles were hand-searched using the Scopus database. Eligible studies were assessed using the Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices, as well as the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. All screening, extraction, and appraisal were completed in duplicate with two independent reviewers.
Main Outcome Measure(s)
Patient-reported or provider-reported views on LGBTQ+ cultural competence in fertility care, including barriers and facilitators to inclusive care.
Result(s)
Of the 1,747 original database citations, we included 25 studies that met the inclusion criteria. Of the 21 studies that evaluated patient perspectives, 13 studies targeted same-sex cisgender couples while the remainder targeted transgender and gender-nonconforming participants (n = 6) or any individual who identified as a sexual or gender minority (n = 2). Key barriers for LGBTQ+ participants included gender dysphoria, heteronormativity, stigmatization, and psychological distress. The lack of tailored information for LGBTQ+ populations was repeatedly highlighted as a concern. Promising solutions included tailored information, psychosocial interventions, gender-neutral language, and inclusive intake processes.
Conclusion(s)
LGBTQ+ individuals face unique barriers in fertility care, as described by both patients and providers. This review describes a number of implementable solutions for equitable care, which should be given priority for both research and hospital interventions.
Research question
What is the fertility preservation (FP) rate among transgender women who received professional fertility counseling compared to transgender men?
Design
This retrospective cohort study included 56 transgender women and 56 transgender men referred to comprehensive fertility counseling at the Gender Clinic of the medical center's Fertility Institute between January 2017 and April 2019. Statistical analyses were performed to compare transgender men with transgender women who preserved fertility and transgender people who preserved fertility and those that did not.
Results
The FP rate of transgender women was significantly higher compared to transgender men (85.7 % vs 35.7 %, respectively, P < 0.001). The FP among transgender women was associated with being older and not having undergone gender-affirming hormone (GAH) treatment. The FP rate was higher among adolescent transgender boys compared to adolescent transgender girls (35% vs 6.25%, respectively, P = 0.005). The duration of GAH treatment among the transgender men who preserved fertility was longer compared to that of the transgender women (70 months vs 18.6 months, respectively, P = 0.05). All transgender boys opted for oocyte cryopreservation, while half of the transgender men who had not started GAH opted for oocyte cryopreservation, and half of those who had already started on GAH opted for embryo cryopreservation.
Conclusions
High FP rates among transgender individuals were found after comprehensive fertility counseling. FP rates among adults were higher among transgender women compared to transgender men, while an opposite trend was found in transgender adolescents.
Transgender adolescents are increasingly seeking hormonal intervention to achieve a body consistent with their gender identity. These treatments include gonadotropin-releasing hormone agonists (GnRHa) to suppress puberty and the gender-affirming hormones testosterone and estrogen. Given that these interventions affect reproductive function, current treatment guidelines recommend prior fertility counseling and access to fertility preservation (FP).¹ However, despite a previous report that 36% of transgender adolescents want biological children in the future,² 3 recent North American studies³⁻⁵ identified that less than 5% of transgender adolescents accessed FP. Whether these low rates reflect service barriers (eg, cost and availability), unwillingness to delay hormonal treatment for FP, and/or an intrinsic lack of desire for FP is unclear.
Background:
Many transgender individuals choose to undergo gender-affirming hormone treatment (GAHT) and/or sex reassignment surgery (SRS) to alleviate the distress that is associated with gender dysphoria. Although these treatment options often succeed in alleviating such symptoms, they can also negatively impact future reproductive potential.
Objective and rationale:
The purpose of this systematic review was to synthesize the available psychosocial and medical literature on fertility preservation (FP) for transgender adolescents and young adults (TAYAs), to identify gaps in the current research and provide suggestions for future research directions.
Search methods:
A systematic review of English peer-reviewed papers published from 2001 onwards, using the preferred reporting items for systematic reviews and meta-analyses protocols (PRISMA-P) guidelines, was conducted. Four journal databases (Ovid MEDLINE, PubMed Medline, Ovid Embase and Ovid PsychINFO) were used to identify all relevant studies exploring psychosocial or medical aspects of FP in TAYAs. The search strategy used a combination of subject headings and generic terms related to the study topic and population. Bibliographies of the selected articles were also hand searched and cross-checked to ensure comprehensive coverage. All selected papers were independently reviewed by the co-authors. Characteristics of the studies, objectives and key findings were extracted, and a systematic review was conducted.
Outcomes:
Included in the study were 19 psychosocial-based research papers and 21 medical-based research papers that explore fertility-related aspects specific for this population. Key psychosocial themes included the desire to have children for TAYAs; FP discussions, counselling and referrals provided by healthcare providers (HCPs); FP utilization; the attitudes, knowledge and beliefs of TAYAs, HCPs and the parents/guardians of TAYAs; and barriers to accessing FP. Key medical themes included fertility-related effects of GAHT, FP options and outcomes. From a synthesis of the literature, we conclude that there are many barriers preventing TAYAs from pursuing FP, including a lack of awareness of FP options, high costs, invasiveness of the available procedures and the potential psychological impact of the FP process. The available medical data on the reproductive effects of GAHT are diverse, and while detrimental effects are anticipated, the extent to which these effects are reversible is unknown.
Wider implications:
FP counselling should begin as early as possible as a standard of care before GAHT to allow time for informed decisions. The current lack of high-quality medical data specific to FP counselling practice for this population means there is a reliance on expert opinion and extrapolation from studies in the cisgender population. Future research should include large-scale cohort studies (preferably multi-centered), longitudinal studies of TAYAs across the FP process, qualitative studies of the parents/guardians of TAYAs and studies evaluating the effectiveness of different strategies to improve the attitudes, knowledge and beliefs of HCPs.
Transgender individuals who undergo gender-affirming medical or surgical therapies are at risk for infertility. Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear. Gender-affirming surgery (GAS) that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility. It is recommended that clinicians counsel transgender patients on fertility preservation (FP) options prior to initiation of gender-affirming therapy. Transmen can choose to undergo cryopreservation of oocytes or embryos, which requires hormonal stimulation for egg retrieval. Uterus preservation allows transmen to gestate if desired. For transwomen, the option for FP is cryopreservation of sperm either through masturbation or testicular sperm extraction. Experimental and future options may include cryopreservation and in vitro maturation of ovarian or testicular tissue, which could provide prepubertal transgender youth an option for FP since they lack mature gametes. Successful uterus transplantation with subsequent live birth is a new medical breakthrough for cisgender women with uterus factor infertility. Although it has not yet been performed in transgender women, uterus transplantation is a potential solution for those who wish to get pregnant. The transgender population faces many barriers to care, such as provider discrimination, lack of information, legal barriers, scarcity of fertility centers, financial burden, and emotional cost. Further research is necessary to investigate the feasibility of experimental FP options, provide better evidence-based information to clinicians and transgender patients alike, and to improve access to and quality of reproductive services for the transgender population.
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.
The majority of transgender and gender nonconforming persons seeking medical care are of reproductive age. Hormonal treatment and sex reassignment surgery, which are used in the management of gender dysphoria, compromise fertility potential. Children and adolescents with gender dysphoria have specific treatment regimens starting with puberty‐blocking medications. According to international guidelines, fertility preservation should be discussed before any hormonal treatment, although our knowledge on the reproductive needs of transgender and gender nonconforming persons is limited. Recently, some data have emerged on fertility management in some centres for the adult population with gender dysphoria. The goal of this review is to summarize the available evidence on the fertility desires and parental roles of transgender and gender nonconforming people. In light of newly emerging societal challenges, we aim to provide some considerations for clinical practice and suggest further areas of research.
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Objective
The aim of this study was to investigate the views of young people (YP) with gender dysphoria and their parents concerning fertility preservation and reproductive and life priorities.
Design
A cross-sectional questionnaire-based study assessed knowledge of potential effects of treatments for gender dysphoria on fertility, current and future life priorities and preferences regarding future fertility/parenting options among YP and parents.
Results
A total of 79 YP (81% assigned female at birth [AFAB], 19% assigned male at birth [AMAB], aged 12–18 years, 68% between ages 16 years and 18 years) and 73 parents participated. The top current life priority for YP among eight options was being in good health ; the least important priority was having children . Anticipated life priorities 10 years from now were ranked similarly. Parents’ rankings paralleled the YP responses; however, parents ranked having children as a significantly higher priority for AFAB compared with AMAB YP in 10 years. The majority of YP (66% AFAB, 67% AMAB) want to be a parent in the future. However, most do not envision having a biological child. A large majority (72% AFAB, 80% AMAB) were open to adoption. None of the YP surveyed pursued fertility preservation.
Conclusion
Fertility is a low current and future life priority for transgender YP. The majority of YP wish to become parents but are open to alternative strategies for building a family. These data may explain in part the reported low rates of fertility preservation among this population. Further studies are needed to assess if life priorities change over time.
Purpose
The primary aims of the study are to examine the rate of attempted fertility preservation (FP) among a Dutch cohort of transgirls who started gonadotropin-releasing hormone analog treatment and the reasons why adolescents did or did not choose to attempt FP.
Methods
The study was a single-center retrospective review of medical records of 35 transgirls who started gonadotropin-releasing hormone analog treatment between 2011 and 2017.
Results
Ninety-one percent of adolescents were counseled on the option of FP. Thirty-eight percent of counseled adolescents attempted FP, and 75% of them were able to cryopreserve sperm suitable for intrauterine insemination or intracytoplasmic sperm injection. Younger and Caucasian transgirls were less likely to attempt FP. No specific reason for declining FP was known in 33% adolescents, 32% of adolescents were not able to produce a semen sample because of early puberty, 17% felt uncomfortable with masturbation, 17% did not want to have children, and 13% wanted to adopt.
Conclusions
One third of adolescents attempted FP, which is much more than the percentage reported in previous studies from the United States. One third of the transgirls could not make use of FP because they were unable to produce a semen sample because of early pubertal stage. For these adolescents, alternatives need to be explored.
This statement explores the ethical considerations surrounding the provision of fertility services to transgender individuals and concludes that denial of access to fertility services is not justified.
In this paper we examine the social and legal conditions in which many transgender people (often called trans people) live, and the medical perspectives that frame the provision of health care for transgender people across much of the world. Modern research shows much higher numbers of transgender people than were apparent in earlier clinic-based studies, as well as biological factors associated with gender incongruence. We examine research showing that many transgender people live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor health. They often experience difficulties accessing appropriate health care, whether specific to their gender needs or more general in nature. Some governments are taking steps to address human rights issues and provide better legal protection for transgender people, but this action is by no means universal. The mental illness perspective that currently frames health-care provision for transgender people across much of the world is under scrutiny. The WHO diagnostic manual may soon abandon its current classification of transgender people as mentally disordered. Debate exists as to whether there should be a diagnosis of any sort for transgender children below the age of puberty.
The purpose of this study was to describe baseline characteristics of participants in a prospective observational study of transgender youth (aged 12-24 years) seeking care for gender dysphoria at a large, urban transgender youth clinic.
Eligible participants presented consecutively for care at between February 2011 and June 2013 and completed a computer-assisted survey at their initial study visit. Physiologic data were abstracted from medical charts. Data were analyzed by descriptive statistics, with limited comparisons between transmasculine and transfeminine participants.
A total of 101 youth were evaluated for physiologic parameters, 96 completed surveys assessing psychosocial parameters. About half (50.5%) of the youth were assigned a male sex at birth. Baseline physiologic values were within normal ranges for assigned sex at birth. Youth recognized gender incongruence at a mean age of 8.3 years (standard deviation = 4.5), yet disclosed to their family much later (mean = 17.1; standard deviation = 4.2). Gender dysphoria was high among all participants. Thirty-five percent of the participants reported depression symptoms in the clinical range. More than half of the youth reported having thought about suicide at least once in their lifetime, and nearly a third had made at least one attempt.
Baseline physiologic parameters were within normal ranges for assigned sex at birth. Transgender youth are aware of the incongruence between their internal gender identity and their assigned sex at early ages. Prevalence of depression and suicidality demonstrates that youth may benefit from timely and appropriate intervention. Evaluation of these youth over time will help determine the impact of medical intervention and mental health therapy.
Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
In 2007, an interdisciplinary clinic for children and adolescents with disorders of sex development (DSD) or gender identity disorder (GID) opened in a major pediatric center. Psychometric evaluation and endocrine treatment via pubertal suppressive therapy and administration of cross-sex steroid hormones was offered to carefully selected patients according to effective protocols used in Holland. Hembree et al.'s (2009) Guidelines for Endocrine Treatment of Transsexual Persons published by the Endocrine Society endorsed these methods. A description of the clinic's protocol and general patient demographics are provided, along with treatment philosophy and goals.
Studies on diagnostic subtypes of gender identity disorder (GID) or gender incongruence (GI), comorbidity and treatment outcome show considerable variability in results. Clinic/country specific factors may account for the contradictory results, but these factors have never been studied. This article is the first of a series reporting on a unique collaborative study of four European gender identity clinics (the European network for the investigation of gender incongruence [ENIGI]). Here, we present the diagnostic procedures of the four clinics (Amsterdam, Ghent, Hamburg, and Oslo), the standard battery of instruments, and the first results regarding applicants with GI who seek treatment. Applicants in the four clinics did not differ in living situation, employment status, sexual orientation, and age of onset of GI feelings. However, the Amsterdam and Ghent clinic were visited by a majority of natal males, whereas Hamburg and Oslo see more natal females. Male applicants were older than female applicants within each country, but female applicants in one country were sometimes older than male applicants in another country. Also, educational level differed between applicants of the four clinics. These data indicate that certain sociodemographic and/or cultural characteristics of applicants have to be taken into account in future studies.
To assess the prognosis of individuals with gender identity disorder (GID) receiving hormonal therapy as a part of sex reassignment in terms of quality of life and other self-reported psychosocial outcomes.
We searched electronic databases, bibliography of included studies and expert files. All study designs were included with no language restrictions. Reviewers working independently and in pairs selected studies using predetermined inclusion and exclusion criteria, extracted outcome and quality data. We used a random-effects meta-analysis to pool proportions and estimate the 95% confidence intervals (CIs). We estimated the proportion of between-study heterogeneity not attributable to chance using the I(2) statistic.
We identified 28 eligible studies. These studies enrolled 1833 participants with GID (1093 male-to-female, 801 female-to-male) who underwent sex reassignment that included hormonal therapies. All the studies were observational and most lacked controls. Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68-89%; 8 studies; I(2) = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56-94%; 7 studies; I(2) = 86%); 80% reported significant improvement in quality of life (95% CI = 72-88%; 16 studies; I(2) = 78%); and 72% reported significant improvement in sexual function (95% CI = 60-81%; 15 studies; I(2) = 78%).
Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.
Fertility preservation for transgender individuals: a review
- Ainsworth