Fertility preservation in transgender people

The World Health Organization (WHO) defines reproductive health as a complete state of physical, mental and social well-being which implies, among other things, the ability of a person to reproduce and the freedom to decide when.

This definition tells us that reproductive health is not just the absence of a disease. Furthermore, since 2016, the right to medical care for those with reproductive desire, and could not reproduce without technological or medical intervention, alluding and protecting the rights for people with divergent sexual orientations (LGTBQI) has been recognized.

In the case of transgender people, infertility or even sterility can appear as a consequence of gender-reassert treatments, both with surgical procedures and hormonal treatments.

Before beginning the gender transition process, it’s important to discuss the possibility of a future or present desire for motherhood or fatherhood, and to expose and discuss about the available options to preserve fertility for the future.

Transgender men

The chronic administration of testosterone can induce a reduction in the number of ovarian follicles and change their appearance and function which reduces reproductive possibilities. Despite the fact that there’s evidence telling us that it’s possible to retrieve eggs after stopping hormonal therapy, it’s advisable to carry out a fertility preservation prior to it as there’s no certainty regarding a safe dose and how long to use exogenous hormonal therapy.

On the other hand, it’s evident that the removal of both ovaries (bilateral oophorectomy) or of the uterus (hysterectomy) would lead to a situation in which genetic affiliation with a future embryo is not possible (need for egg donation, which could come from the couple if a woman) and / or also the absence of a gestation possibility.

In patients who have already passed puberty, the options we have are the following.

Eggs vitrification

Vitrification (flash freezing) of oocytes is currently a more than established technique that has practically no differences from fresh oocytes.

In order to freeze your eggs, it’s necessary to undergo what we call “controlled ovarian stimulation“. This is a medical process in which we use daily injections of substances called gonadotropins for 9-12 days, which will allow us to improve the natural functioning of the body, going from having a single egg available to having several. Later, these eggs will be rescued transvaginally in a surgical process called “oocyte retrieval” and those that are suitable will be cryopreserved.

There are specific stimulation protocols for these cases which minimize the increase in estrogens in the blood, minimizing those symptoms derived from their action that could be more difficult to cope with.

Likewise, we want to point out the importance of an individualized treatment in which the same doctor is responsible for all follow-up.

In case of having started a treatment with androgens previously, it is advisable to suspend it between 3 and 6 months in advance.

Embryo vitrification

A step beyond what was previously stated would be the vitrification of the embryos. Once the eggs were recovered, those mature ones would be fertilized with a semen sample, whether the couple was a male or a donor. Once this is done, the embryos develop in the laboratory until they are about 5-6 days old, at which point we call them blastocysts and they have already demonstrated their ability to lead to pregnancy.

Eventually these embryos could be implanted in the trans-man with a uterus or in the partner in the case of a cis-woman.

Ovarian tissue freezing

This is a technique that would be of special interest in two specific situations: in patients who have not yet begun puberty and; as a technique that would avoid hormonal stimulation in those patients who might be more uncomfortable and that could also be performed during conformity or reassignment surgery.

This technique consists of keeping small wedges of ovarian tissue frozen. Later it would be possible either to reimplant them and seek a natural pregnancy with or without ovarian stimulation or to try to obtain mature oocytes in the laboratory.

Despite the fact that more than 60 births have been described with this technique, today it is considered experimental by scientific societies.

Transgender Women

The use of anti-androgens and additive estrogen therapy has a negative effect on testicular function and its morphology. It’s possible that together or separately they alter the maturation of the sperm, reducing their number and motility. Although these effects appear reversible, the evidence is not clear. Likewise, there’re doubts about a safe dose and time of use.

On the other hand, reassignment surgery, with orchiectomy and penectomy, would lead to sterility.

Sperm freezing

Sperm freezing is a simple method that allows to preserve sex cells in patients who have already started puberty. It consists of freezing the sperm ejaculate, obtained by masturbation or through electrostimulation. It is a well-established technique that offers excellent results in future fertilizations.

Testicular PAAF

Surgical retrieval of sperm and freezing is a possibility in post-pubertal patients.

Testicle biopsy ad spermatic tissue conservation

It can be done during reassignment surgery. In post-pubertal patients, it allows the recovery of mature sperm. In patients who have not started puberty, it is an experimental technique that would allow the preservation of immature sperm. For a prospective conception, it would be necessary to reimplant the tissue or a sperm maturation in the laboratory, followed by an assisted reproductive technique.

Embryo vitrification

In this case, the eggs could be from the couple or from a donor. Regarding a possible pregnancy, in the event that the couple is male-cis, there would be two possible options: either surrogacy, currently illegal in Spain, or uterus transplantation, currently an experimental technique despite having already obtained births.

All the great scientific societies consider essential to discuss the preservation of fertility before carrying out any type of therapy for gender conformity.

When we speak of “preserving fertility” we refer to the freezing of sex cells, current evidence allows us to think of a realization of the reproductive project that motivated their conservation.

Although fertility preservation techniques can increase gender dysphoria, published studies show a high tolerance for them and a majority of satisfaction with the fertility preservation process.

Dr Cristina García-Ajofrín, gyneacologist at Instituto Bernabeu