Dr Eliran Mor MD

 Colpectomy; After removing of the vaginal tissue transvaginal ultrasound and pick-up is no longer feasible and needs to be transabdominal ultrasound-guided or laparoscopic, this results into a higher complication risk during ovum pick-up and a lower number of retrieved oocytes.

 Adolescents; Fertility preservation is not necessary in assigned female at birth adolescents since they can most likely pursue this at a later age if they are willing to temporarily discontinue testosterone at that time. Due to the invasiveness of the procedure it may be disruptive to perform the procedure in virgo/very young patients, nonetheless it is technically possible and successful (Amir, Oren, et al., Citation2020) also after using PS (Insogna et al., Citation2020; Martin et al., Citation2021).

 Ovarian cortex cryopreservation; In vitro maturation (IVM) is still experimental due to unsuccessful fertilization techniques (Lierman et al., Citation2021). Currently, ovarian cortex is only successful with autologous transplantation (Dolmans et al., Citation2021), which is no feasible option for most TGD people. For young adults ovarian hyperstimulation is not always feasible before oophorectomy, due to increasing gender dysphoria triggered by internal examinations, hormone injections, and bleeding. For these persons ovarian cortex preservation may be considered, with possible future techniques for IVM in sight. For some autologous transplantation may be an option in the future if their desire for children develops in the absence of IVM strategies at that time.

 Costs; In countries were fertility preservation is offered by health care insurance there is a higher fertility preservation rate (Amir, Yaish, Oren, et al., Citation2020; Brik et al., Citation2019; Mattelin et al., Citation2022). In the countries with self-pay the main barrier for pursuing fertility preservation are costs (Rogers et al., Citation2021).

 Future gamete use; The use of stored gametes is largely depended on the gametes of the future partner, the carrier (e.g. TGD person themselves, partner or gestational carrier) and the use of donor gametes. Before the start of fertility preservation we advise to discuss the options related to the patient.

 Oocyte donation; If the pregnancy is carried by a partner or gestational carrier via oocyte donation of the TGD person we advise to discuss the medical risks (i.e. higher risk for pre-eclampsia (Keukens et al., Citation2022) and the legal and ethical difficulties of oocyte donation.

 Timing; We advise sperm banking before the start of PS or GAHT. Since most adolescents continue with GnRH agonist (van der Loos et al., Citation2022) as anti-androgen, spermatogenesis will never be initiated (de Nie et al., Citation2022) and after starting GAHT most studies show impaired or absent spermatogenesis (Jiang et al., Citation2019; Jindarak et al., Citation2018; Leavy et al., Citation2017; Sinha & Ferrando, Citation2020).

 Results of cryopreservation; Studies show an impaired semen quality before the start of GAHT. Therefore we advise to evaluate trans specific life-style factors (e.g. ejaculation frequency, wearing tight undergarments, and tucking) and discuss the different semen quality outcomes and consequences of intrauterine insemination (IUI), in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) for future use. For example, if the semen quality is low, discuss a cessation of tucking for 3 months (time to full regeneration) before obtaining a new semen specimen. Taken into consideration what the impact of these adaptations mean for someone’s personal life.

 Restoring spermatogenesis; PS reversibly inhibits spermatogenesis but, there is limited evidence on the time to restore spermatogenesis after starting PS (Adeleye et al., Citation2023; Peri et al., Citation2021). For GAHT the timeline is uncertain and can vary widely (3–18 months) based on the type of anti-androgen therapy that was used (Adeleye et al., Citation2019; de Nie et al., Citation2023; Sermondade et al., Citation2021). In presents of the testis, conception via penis-vagina intercourse after discontinuing GAHT is still successful (de Nie et al., Citation2023). For both sperm banking and conception via intercourse we suggest semen analysis every 3 months after discontinuing GAHT.

 Azoospermia; Testicular sperm extraction (TESE) may be performed when there is a non-obstructive azoospermia during sperm banking via masturbation or an inability for masturbation due to severe genital dysphoria. First, optimize (trans specific) life-style factors for 3 months, if present, similar to semen cryopreservation before performing a TESE.

 Adolescents; TESE is an option for adolescents in early puberty who are not able to physically or mentally perform a semen sample via masturbation. This is probably successful from Tanner 3–4, with testicular volume > 10 ml (Peri et al., Citation2021) and therefore may require a delay in the start of PS. A TESE may be combined with placement of the subcutaneous GnRH agonist implant. Children born after TESE-ICSI procedure from cisgender males show no long-term effects on development and health outcomes (Meijerink et al., Citation2016).

 Testicular tissue cryopreservation; Spermatogonial stem cells or testicular tissue cryopreservation are still experimental for both autologous transplantation and IVM (Wyns et al., Citation2021). Since autologous transplantation is not possible after orchiectomy TGD people will be depended on IVM.

 Costs; In countries were fertility preservation is coffered by health care insurance there is a higher fertility preservation rate (Amir, Yaish, Oren, et al., Citation2020; Brik et al., Citation2019; Mattelin et al., Citation2022). In the countries with self-pay the main barrier for pursuing fertility preservation are costs (Rogers et al., Citation2021).

 Future gamete use; The use of stored gametes is largely depended on the gametes of the future partner, the carrier (e.g. partner with uterus or gestational carrier) and the use of donor gametes. Before the start of fertility preservation we advise to discuss the options related to the patient.

 TGD people may have different desires, values, challenges and considerations concerning parenthood compared to cisgender people. During their transition TGD people may experience changes in their fertility desires as they explore their gender identity and undergo medical transition. Therefore, it is of utmost importance that all TGD people have access to gender sensitive and culturally competent fertility counseling and preservation before and during their medical transition. Fertility preservation is a crucial aspect of transgender healthcare that enables TGD people to have the option of geneticparenthood. Fertility preservation still holds lots of barriers for TGD people. For example, lack of access to healthcare services, discriminatory laws that prohibit assisted reproductive technology, adoption, or surrogacy for TGD people and financial constraints by insufficient healthcare insurance. To promote equitable access to reproductive healthcare for all TGD people, it is crucial to challenge unjust laws and policies and replace them with evidence-based, inclusive practices.

 Adeleye, A. J., Stark, B. A., Jalalian, L., Mok-Lin, E., & Smith, J. F. (2023). Evidence of spermatogenesis in the presence of hypothalamic suppression and low testosterone in an adolescent transgender female: A case report. Transgender Health, 8(1), 104–107. https://doi.org/10.1089/trgh.2021.0034

 Anderson, R. A., Amant, F., Braat, D., D'Angelo, A., Lopes, S. M. C. D., Demeestere, I., Dwek, S., Frith, L., Lambertini, M., Maslin, C., Moura-Ramos, M., Nogueira, D., Rodriguez-Wallberg, K. (2020). ESHRE guideline: Female fertility preservation. Human Reproduction Open, 2020(4), hoaa052. https://doi.org/10.1093/hropen/hoaa052

 Bahadur, G., Homburg, R., Jayaprakasan, K., Raperport, C. J., Huirne, J. A. F., Acharya, S., Racich, P., Ahmed, A., Gudi, A., Govind, A., & Jauniaux, E. (2023). Correlation of IVF outcomes and number of oocytes retrieved: A UK retrospective longitudinal observational study of 172 341 non-donor cycles. BMJ Open, 13(1), e064711. https://doi.org/10.1136/bmjopen-2022-064711

 Bailie, E., Maidarti, M., Hawthorn, R., Jack, S., Watson, N., Telfer, E., & Anderson, R. (2023). The ovaries of transgender men indicate effects of high dose testosterone on the primordial and early growing follicle pool. Reproduction and Fertility, 4(2), 335. https://doi.org/10.1530/RAF-22-0102

Dr Eliran

 Brik, T., Vrouenraets, L., Schagen, S. E. E., Meissner, A., de Vries, M. C., & Hannema, S. E. (2019). Use of fertility preservation among a cohort of transgirls in the Netherlands. The Journal of Adolescent Health, 64(5), 589–593. https://doi.org/10.1016/j.jadohealth.2018.11.008

 Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., de Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green, J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F. L., Monstrey, S. J., Motmans, J., Nahata, L., … Arcelus, J. (2022). Standards of care for the health of transgender and gender diverse People, Version 8 (vol 23, pg S1, 2022). International Journal of Transgender Health, 23(sup1), S1–S259. https://doi.org/10.1080/26895269.2022.2125695

 de Nie, I., Mulder, C. L., Meißner, A., Schut, Y., Holleman, E. M., van der Sluis, W. B., Hannema, S. E., den Heijer, M., Huirne, J., van Pelt, A. M. M., & van Mello, N. M. (2022). Histological study on the influence of puberty suppression and hormonal treatment on developing germ cells in transgender women. Human Reproduction, 37(2), 297–308. https://doi.org/10.1093/humrep/deab240

 de Nie, I., van Mello, N. M., Vlahakis, E., Cooper, C., Peri, A., den Heijer, M., Meißner, A., Huirne, J., & Pang, K. C. (2023). Successful restoration of spermatogenesis following gender-affirming hormone therapy in transgender women. Cell Reports. Medicine, 4(1), 100858. https://doi.org/10.1016/j.xcrm.2022.100858

 Dolmans, M. M., von Wolff, M., Poirot, C., Diaz-Garcia, C., Cacciottola, L., Boissel, N., Liebenthron, J., Pellicer, A., Donnez, J., & Andersen, C. Y. (2021). Transplantation of cryopreserved ovarian tissue in a series of 285 women: A review of five leading European centers. Fertility and Sterility, 115(5), 1102–1115. https://doi.org/10.1016/j.fertnstert.2021.03.008

 Ellis, S. A., Wojnar, D. M., & Pettinato, M. (2015). Conception, pregnancy, and birth experiences of male and gender variant gestational parents: It’s how we could have a family. Journal of Midwifery & Women’s Health, 60(1), 62–69. https://doi.org/10.1111/jmwh.12213

 Greenwald, P., Dubois, B., Lekovich, J., Pang, J. H., & Safer, J. (2022). Successful in vitro fertilization in a cisgender female carrier using oocytes retrieved from a transgender man maintained on testosterone. AACE Clinical Case Reports, 8(1), 19–21. https://doi.org/10.1016/j.aace.2021.06.007

 Israeli, T., Preisler, L., Kalma, Y., Samara, N., Levi, S., Groutz, A., Azem, F., & Amir, H. (2022). Similar fertilization rates and preimplantation embryo development among testosterone-treated transgender men and cisgender women. Reproductive Biomedicine Online, 45(3), 448–456. https://doi.org/10.1016/j.rbmo.2022.04.016

 Kerman, H. M., Pham, A., Crouch, J. M., Albertson, K., Salehi, P., Inwards-Breland, D. J., & Ahrens, K. R. (2021). Gender diverse youth on fertility and future family: A qualitative analysis. The Journal of Adolescent Health, 68(6), 1112–1120. https://doi.org/10.1016/j.jadohealth.2021.01.002

 Kolbuck, V. D., Sajwani, A., Kyweluk, M. A., Finlayson, C., Gordon, E. J., & Chen, D. (2020). Formative development of a fertility decision aid for transgender adolescents and young adults: A multidisciplinary Delphi consensus study. Journal of Assisted Reproduction and Genetics, 37(11), 2805–2816. https://doi.org/10.1007/s10815-020-01947-8

 Kumar, S., Mukherjee, S., O'Dwyer, C., Wassersug, R., Bertin, E., Mehra, N., Dahl, M., Genoway, K., & Kavanagh, A. G. (2022). Health outcomes associated with having an oophorectomy versus retaining one’s ovaries for transmasculine and gender diverse individuals treated with testosterone therapy: A systematic review. Sexual Medicine Reviews, 10(4), 636–647. https://doi.org/10.1016/j.sxmr.2022.03.003

 Lai, T. C., Davies, C., Robinson, K., Feldman, D., Elder, C. V., Cooper, C., Pang, K. C., & McDougall, R. (2021). Effective fertility counselling for transgender adolescents: A qualitative study of clinician attitudes and practices. BMJ Open, 11(5), e043237. https://doi.org/10.1136/bmjopen-2020-043237

 Leavy, M., Trottmann, M., Liedl, B., Reese, S., Stief, C., Freitag, B., Baugh, J., Spagnoli, G., & Kolle, S. (2017). Effects of elevated beta-estradiol levels on the functional morphology of the testis – New Insights. Scientific Reports, 7(1), 39931. https://doi.org/10.1038/srep39931

 Lierman, S., Tolpe, A., De Croo, I., De Gheselle, S., Defreyne, J., Baetens, M., Dheedene, A., Colman, R., Menten, B., T'Sjoen, G., De Sutter, P., & Tilleman, K. (2021). Low feasibility of in vitro matured oocytes originating from cumulus complexes found during ovarian tissue preparation at the moment of gender confirmation surgery and during testosterone treatment for fertility preservation in transgender men. Fertility and Sterility, 116(4), 1068–1076. https://doi.org/10.1016/j.fertnstert.2021.03.009

 Meijerink, A. M., Ramos, L., Janssen, A. J. W. M., Maas-van Schaaijk, N. M., Meissner, A., Repping, S., Mochtar, M. H., Braat, D. D. M., & Fleischer, K. (2016). Behavioral, cognitive, and motor performance and physical development of five-year-old children who were born after intracytoplasmic sperm injection with the use of testicular sperm. Fertility and Sterility, 106(7), 1673–1682.e5. https://doi.org/10.1016/j.fertnstert.2016.09.011

 Moseson, H., Fix, L., Hastings, J., Stoeffler, A., Lunn, M. R., Flentje, A., Lubensky, M. E., Capriotti, M. R., Ragosta, S., Forsberg, H., & Obedin-Maliver, J. (2021). Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: Results from a national, quantitative survey. International Journal of Transgender Health, 22(1–2), 30–41. https://doi.org/10.1080/26895269.2020.1841058