Fertility Concerns of the Transgender Patient

Philip J. Cheng; Alexander W. Pastuszak; Jeremy B. Myers; Isak A. Goodwin; James M. Hotaling

Disclosures

Transl Androl Urol. 2019;8(3):209-218. 

In This Article

Abstract and Introduction

Abstract

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.

Introduction

There are an estimated 1.4 million transgender individuals in the United States, representing 0.6% of the population.[1] The term "transgender" describes a person whose gender identity is incongruent with the phenotypic sex assigned at birth. Transgender people may choose to transition from female to male (transgender man, transman, or FTM) or male to female (transgender woman, transwoman, or MTF).

The gender affirmation process may include emotional, social, medical, and surgical aspects of transition, though not all transgender people desire medical or surgical intervention.[2,3] Some transgender individuals undergo gender-affirming interventions to masculinize or feminize body parts to bring their physical appearance more in line with their gender identity. According to the 2015 United States Transgender Survey (USTS), which surveyed 27,715 respondents, 49% had received gender-affirming hormone therapy (GAHT), while 25% had undergone some form of gender-affirming surgery (GAS).[4] A minority of transgender individuals had undergone gender-affirming bottom surgery, such as hysterectomy (14%), metoidioplasty (2%), and phalloplasty (3%) for transmen and vaginoplasty/labiaplasty (12%) and orchiectomy (11%) for transwomen.[4] Both transgender men and women are at risk of losing their reproductive potential during the process of medical or surgical transition with GAHT or gender-affirming bottom surgery. For instance, transmen who undergo hysterectomy and oophorectomy and transwomen who undergo orchiectomy are rendered permanently sterile. Accordingly, the World Professional Association for Transgender Health (WPATH), the Endocrine Society, the American Society for Reproductive Medicine (ASRM), and the European Society of Human Reproduction and Embryology (ESHRE) recommend that clinicians counsel their transgender patients on the potential for reduced fertility and fertility preservation (FP) options (Table 1) prior to administering puberty-suppressing medications or GAHT.[2,3,5,6]

Urologists, gynecologists, and plastic surgeons are usually the primary surgeons performing gender-affirming bottom surgeries. Unlike many professional organizations, the American Urological Association (AUA) does not have an official statement on transgender care or guidelines for the application of gender-affirming hormone therapy or surgery. Nonetheless, it is important for urologists to inform their patients of the fertility risks of undergoing GAS and educate them on their options. The purpose of this article is to review the different fertility concerns that transgender individuals face and examine the current and potential future options for fertility preservation while also providing clinicians a framework for educating transgender patients.

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