Iris de Nie

100 C H A P T E R 6 CONCLUSION Counseling of transgender women about the effect of medical treatment on fertility and the currently available options for fertility preservation remains essential. However, for some transgender women with a wish for fertility preservation, there are barriers that prevent the use of semen cryopreservation. For example some initiate medical treatment in early puberty before the development of complete spermatogenesis, some are unable to masturbate, and some feel that a temporary cessation of GAHTwould be too psychologically and physically disruptive. The results of this study show that there may still be options for fertility preservation using orchiectomy specimens obtained during gGAS. In a small percentage of transgender women who initiated medical treatment in Tanner stage 4 or higher, spermatozoa could have been harvested from the orchiectomy specimen at time of gGAS. In addition, the vast majority ( > 85%) of transgender women in our cohort could still opt for cryopreservation of testicular tissue harboring spermatogonial stem cells. A complete absence of germ cells was only observed in a small number (7%) of transgender women in our cohort, who all commenced GAHT as adult. The possibilities for fertility preservation seem irrespective of pre-operative cessation of GAHT and the duration of GAHT prior to gGAS. Initiation of medical treatment in early-pubertal adolescents (Tanner stage 2-3) limits the ability to retrieve mature spermatozoa that can directly be used for assisted reproductive techniques. However, if maturation techniques like in vitro spermatogenesis become available in the future, harvesting germ cells from orchiectomy specimens might be a promising option for those who are otherwise unable to have biological children. Supplementary Table 1. The Modified Johnsen’s scoring system Johnsen score Characteristics 1 no recognizable seminiferous epithelium (sclerosis) 2 Sertoli cell only (SCO), absence of germ cells 3 only the presence of spermatogonia alongside Sertoli cells, but no spermatocytes 4 presence of 1-10 spermatocytes, but no spermatids 5 presence of ≥ 10 spermatocytes, but no spermatids 6 presence of 1-10 round spermatids, but no elongated spermatids 7 presence ≥ 10 round spermatids, but no elongated spermatids 8 presence of 1-10 elongated spermatids 9 presence of ≥ 10 elongated spermatids, but a disorganized epithelium with released immature and apoptotic cells in the lumen 10 presence of ≥ 10 elongated spermatids without immature and apoptotic cells in lumen