Transgender adolescent and young adult patients are increasingly requesting medical affirming interventions (MAIs) to enable them to experience physiologic changes that align with their gender identity. In doing so, they may be compromising their fertility with the use of gonadotoxic therapies. To better understand outcomes in fertility preservation in feminizing transgender patients, Barnard et al. (10.1542/peds.2018-3943) share with us in a study being released in our journal this week. This study provides detailed data collected on 11 transgender feminizing patients at the University of Pittsburgh, 8 patients prior to initiating MAI therapy and 3 after, with 10 able to provide at least one semen collection. Of the two patients who had begun MAI, one who had been treated with leuprolide acetate discontinued it and after 5 months was able to again demonstrate spermatogenesis. Another patient treated with spironolactone and estradiol had these discontinued for 4 months leading up to orchiectomy and was unable to produce viable sperm in that pre-surgical interval.
Should transgender feminizing patients seek fertility preservation? To answer that question, we asked a specialist in this field Dr. Jason Rafferty from Brown University to provide an accompanying commentary (10.1542/peds.2019-2000). Dr. Rafferty discusses reasons why teens and young adults are not focused on fertility preservation, and yet convinces us and hopefully these patients of the need to at least discuss this issue prior to embarking on MAI treatments. Dr. Rafferty also notes that we need more studies to determine how long to stop these treatments to reverse azoospermia. If you have not considered the issue of subsequent fertility in your patients with gender dysphoria requesting hormonal or surgical treatment to transition to their gender identity, this study and commentary make a great pairing to educate you and in turn your patients to consider at least being counseled prior to proceeding with gonadotoxic therapies.