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Current trans treatment guidelines recommend prior fertility counseling, access to fertility preservation

Despite a previous report that 36% of transgender adolescents want biological children in the future, recent studies identified that less than 5% of transgender adolescents accessed fertility preservation (FP).

Photo by Sharon McCutcheon from Unsplash.com

Despite a previous report that 36% of transgender adolescents want biological children in the future, recent studies identified that less than 5% of transgender adolescents accessed fertility preservation (FP).

This is according to a study that noted that whether these low rates reflect service barriers (eg, cost and availability), unwillingness to delay hormonal treatment for FP, and/or an intrinsic lack of desire for FP is unclear.

“Transgender adolescents are increasingly seeking hormonal intervention to achieve a body consistent with their gender identity. These treatments include gonadotropin-releasing hormone agonists (GnRHa) to suppress puberty and the gender-affirming hormones testosterone and estrogen. But since these interventions affect reproductive function, current treatment guidelines recommend prior fertility counseling and access to FP,” stated Kenneth C. Pang, Angus J. S. Peri, Hsu En Chung, et al, authors of “Rates of Fertility Preservation Use Among Transgender Adolescents” that appeared in JAMA Pediatrics.

To assess FP use, the researchers conducted a retrospective review of all individuals with gender dysphoria who had commenced receiving GnRHa and/or gender-affirming hormones from January 1, 2003, until June 1, 2017. Information on birth-assigned sex, age, hormonal treatment, fertility counseling, and FP use was extracted from the medical record. Data were analyzed between August 2017 and July 2019. The P value threshold considered significant was .05 (2-tailed), and statistical analysis was performed using Prism version 7.0 (GraphPad).

One hundred two patients received fertility counseling from their pediatrician prior to commencing hormones. Of 53 individuals who were assigned male at birth (AMAB), 23 received counseling prior to taking GnRHa and 30 prior to taking estrogen, and 14 received additional consultation from an andrologist.

Of 49 individuals assigned female at birth (AFAB), three received counseling prior to taking GnRHa and 46 prior to taking testosterone, and 47 received additional consultation from a gynecologist. The mean age at counseling was 15.6 years (range, 10.8-18.3 years), with no significant difference between sexes.

Among 49 individuals who were AFAB, none attempted FP, with 16 stating no reason; among the other 33, the main reason was a plan to reassess fertility options when older. Conversely, 33 of 53 individuals who were AMAB (62%) pursued FP, of whom 22 successfully froze sperm after providing a masturbatory sample (mean [SD] age, 15.6 [1.4] years).

The remaining 11 underwent testicular biopsy (which is well suited to those in early puberty), and this group was significantly younger (mean [SD] age, 13.9 [1.5] years; P = .003). Five of these 11 individuals were found to have mature sperm, while the other 6 had germ cells only, all of which were cryopreserved.

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The researchers found that:

  • All patients who were AFAB declined FP
  • 62% of patients who were AMAB pursued FP ( “suggesting that most transfeminine adolescents have an intrinsic desire to preserve their fertility”)
  • Unwillingness to delay hormone treatment is a common reason for forgoing FP
  • FP costs is a big consideration for AFAB and AMAB
  • The importance of providing different FP options needs to be stressed

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