Transgender Youth May Produce Viable Sperm After Stopping Feminizing Medications

By Marilynn Larkin

August 06, 2019

NEW YORK (Reuters Health) - Fertility preservation is possible, though not certain, for young feminizing individuals who have already started gender-affirming therapy, a small case study reveals.

"Based on limited studies, it appears that family building, especially having genetic children, is important for adult transgender patients," Dr. Hanna Valli-Pulaski of Magee-Womens Research Institute in Pittsburgh told Reuters Health by email.

"Unfortunately, there is little known about the effect of gender-affirming therapies on fertility," she noted. "Therefore, we encourage transgender patients to consider freezing either their sperm or eggs prior to starting hormone therapy."

"Our study is the first to look at the sperm parameters - both quantity and quality - for a group of young feminizing patients, some of whom had already started gender-affirming therapy," she added. "This allowed us to see how treatments such as puberty blockers, testosterone blockers, and estrogen therapy may affect sperm production."

Dr. Valli-Pulaski and colleagues enrolled 11 feminizing transgender patients who accepted a referral for fertility preservation. A consultation occurred at median age of 19, and 10 patients attempted and completed at least one semen collection.

As reported online August 5 in Pediatrics, eight individuals cryopreserved semen before initiating treatment. All showed low morphology; however, other semen analysis parameters were normal. "That means that we expect the sperm to be able to fertilize an egg and produce offspring," Dr. Valli-Pulaski said.

One person who discontinued leuprolide acetate to attempt fertility preservation experienced transient azoospermia for five months, then produced viable sperm.

"Another individual had been on a testosterone blocker and estrogen for two years and was also not producing any sperm," she noted. "Even after stopping both medications for four months, she was still not producing sperm. It is unclear whether sperm production would have returned if more time off medication was given."

"It is important to talk to transgender people about fertility preservation, regardless of their age," she stressed. "Fertility and having genetic children should also be periodically revisited, even after gender-affirming therapy has begun."

"Our study offers hope that even after starting therapy, fertility preservation may still be an option for adolescents and young adults and should be offered to patients even if they have already started their transition," she said.

"The follow-up studies for this case series include a prospective study with an increased number of participants to determine the length of time needed to discontinue feminizing medications for fertility to return, and whether sperm production is possible after starting estrogen therapy," Dr. Valli-Pulaski concluded.

Dr. Jason Rafferty of Hasbro Children's Hospital in Providence, Rhode Island, author of a related editorial, said the study "provides a valuable and timely assessment of semen samples obtained either prior to or after medical-affirming interventions, specifically puberty blockers or estradiol."

The findings underscore "the importance of fertility counseling, family planning, and access to affordable fertility services, especially prior to starting medical affirming interventions," he said in an email to Reuters Health.

"Research shows that transgender youth have an interest in learning more about fertility and the standard of care is for providers to discuss the topic prior to starting medical affirming interventions," he said. "But few transgender youth endorse that these discussion are occurring."

"Overall, there is a critical lack of research into the fertility needs of transgender individuals and gender-affirming options for preservation," Dr. Rafferty concluded.


Pediatrics 2019.