ESPE Abstracts (2019) 92 S6.3

Gynecological Aspects and Fertility Issues in Transgender Adolescents

Mick Van Trotsenburg

UniBureau genderPRO, Vienna, Austria. Universitätsklinikum St.Pölten-Lilienfeld, Lilienfeld, Austria

This presentation briefly gives an overview of typical gynaecological issues and fertility options of transgender adolescents.

Typical gynaecological complaints and treatment options will be addressed: e.g. amenorrhea induction prior to cross-sex hormones, irregular bleeding, dysmenorrhea, vaginal discharge but also the limitations of gynaecological examination in female asssigned adolescents.

National and international organizations, including the World Professional Association for Transgender Health, American Society for Reproductive Medicine, and Endocrine Society have put forth guidelines recommending that transgender individuals are counselled about fertility preservation options prior to initiating gender-affirming treatment. But what to tell adolescents desperately seeking gender-affirmative treatment and anxious for delay of the transitional trajectory? And parents who often prioritize fertility preservation to maintain an open future for their child ?

In adult transwomen, semen cryopreservation is typically straightforward but not for adolescents. Is sperm quality harvested at adolescent age sufficient to say with good conscience that expensive cryopreservation for up to 10 or 20yrs is worth the effort? At age 13 boys experience on average the first ejaculation and at age 17 on average normal spermatozoal motility is reached. For transwomen at adolescent age and prior to treatment sperm cryopreservation possible age-related altered sperm quality needs to be addressed . For transgirls under pubertyblocking treatment prior to cross-sex hormones semen cryopreservation is no option as it takes months for the HPA-axis to develop and stimulate spermatogenesis. ICSI or testicular tissue preservation, use of spermatogonium stem cells and in vitro-maturation are experimental and may be future options.

For adolescent transmen fertility preservation appears even more dificult. Oocyte cryopreservation include controlled ovarian hyperstimulation, and transvaginal ultrasound-guided ovarian puncture to harvest eggs. For transmen this procedure may cause great distress by interupting androgen therapy and undergoing ovarian hyperstimulation . Moreover women with elevated androgens are at higher risk for OHSS. Alternatively ovarian tissue preservation may be performed at the same time as gender affirming surgery. Consecutively in-vitro maturation, IVF and embryotransfer either homo- or heterologeously is warranted. For transmen at adolescent age it is likely that ovaries are not fully developed, and hyperstimulation and oocyte retrieval may not be fully succesful.

Overall, it seems mandatory to discuss reproductive options and limitations, also at younger age being very clear about the limited knowledge and experience available possibly impeding with the principles of proper informed consent.

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