By Ashok Agarwal, PhD, HCLD, and Sajal Gupta, MD
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As transgender people gain social acceptance and seek cross-gender medical treatment, urologists are seeing more transgender patients and paying greater attention to their needs. One issue for transgender people considering treatment is its effect on their fertility. In transgender men, hormone therapy leads to decreased spermatogenesis and eventually azoospermia. Sex reassignment surgery, or gender affirmation surgery, results in irreversible loss of natural reproductive capacity in male-to-female transsexuals (transsexual women or transwomen).
Since 2001, the World Professional Association for Transgender Health (WPATH) Standards of Care has recommended discussing fertility issues with transgender patients before they start cross-gender hormonal treatment. But until recent years, the reproductive needs of transgender people weren’t given much consideration. Some reproductive care specialists have had concerns about the impact on children of having a gender-reassigned parent. Also, there is often a lack of communication among the specialists involved in dealing with transgender medical issues and infertility.
ART for transgender people
Assisted reproductive technology offers fertility options and fertility preservation to transsexual people. Before undergoing hormone therapy, transsexual women (TW) can store their sperm in a sperm bank for future use. Sexual orientation will determine how the sperm is used. For TW with female partners, intrauterine insemination, in vitro fertilization or intracytoplasmic sperm injection are options for having genetically related children. TW with male partners face greater difficulties and need egg donation and a surrogate mother.
Research on fertility in this population has been very limited. Cleveland Clinic’s American Center for Reproductive Medicine has participated in two studies that investigated this issue, both in collaboration with University Hospital Ghent in Belgium, which has a relatively large transgender patient population.
In one study, we looked at transsexual women who chose to store sperm starting in 2003 when this service was introduced and discussed with patients during the diagnostic phase of treatment. From 2003 to 2011, 27 transsexual women chose sperm banking at Ghent and two at Cleveland Clinic; their median age was 28.9. Regarding sexual orientation, half of the Ghent participants were mainly attracted to women, eight were attracted to men, four were attracted to both sexes and in three cases, sexual orientation was not known. Only one TW used her sperm for donor insemination in her partner and a healthy child was born.
Drs. Agarwal and Gupta in their lab. This LN2 storage tank contains semen samples preserved in cryoprotective media at -196ºC for long-term storage.
Transition concerns may trump fertility concerns
In 2011, only 15 percent of TW Ghent patients chose to freeze their sperm. Based on limited research and our clinical impressions, many TW are more concerned with their transition over future fertility or may not be aware of fertility options. Also, TW are seeking treatment at a younger age before they consider having children. One study found that TW feel that storing sperm means that they cannot break from their male past. In addition, several TW mentioned that they find masturbation, especially in a hospital setting, difficult.
The second study, which also included researchers from Mount Sinai Medical Center, Case Western Reserve University and the University of British Columbia, evaluated sperm quality in the same 29 TW participants. Pre-freeze (PF) semen parameters were measured in all participants and a 24-hour post-thaw (PT) analysis was done on the two Cleveland Clinic patients.
The PF data showed a high incidence of oligozoospermia (27.58 percent), asthenozoospermia (31 percent) and teratozoospermia (31 percent). The mean sperm concentration was 46.9 x 106 ml, mean percent motility was 42.9 and mean percent sperm morphology 7.98 by Kruger’s method.
Of the two Cleveland Clinic patients, aged 17 and 18 at the time of sperm donation, the 17-year-old had poor sperm quality and the 18-year-old had high sperm concentration and sperm motility. After freezing, the sperm samples from the first patient were suited to IVF/ICSI use only while the second patient’s sperm contained adequate numbers of motile spermatozoa for intrauterine insemination (IUI).
Sperm quality issues
The reason for the overall low sperm quality in TW is not known. Some possible explanations include psychological stress, self-induced high scrotal positioning of the testes, wearing tight underwear, undisclosed feminizing hormone use, androgen receptor gene polymorphism and unidentified genetic disorders.
Cleveland Clinic is currently collecting additional data related to fertility in this population. Understanding both the reasons why a low percentage of TW choose sperm banking and why sperm quality is poor in this population will help clinicians to provide more informed counseling to patients regarding their fertility options and enhance patient care.
Dr. Agarwal is Director of Cleveland Clinic Glickman Urological & Kidney Institute’s Andrology Center and Reproductive Tissue Bank and the American Center for Reproductive Medicine (ACRM). Dr. Gupta is Assistant Coordinator of Research at the ACRM, and Andrology Center Supervisor.