Iris de Nie

138 C H A P T E R 9 of the American Society for Reproductive Medicine states that fertility clinics should treat all requests for assisted reproduction without regard to gender identity status, since current data do not support concerns that children are harmed from being raised by transgender parents. 68 The results from our survey study, described in chapter 2 , underline the importance of proper fertility counseling since the majority of transgender people developed a desire to have children and many would, in retrospect, have wanted to pursue fertility preservation or keep their biological gonads. Since several years, fertility counseling for adult transgender people is thoroughly embedded in the multidisciplinary approach of our gender identity clinic, and since last year the same has been implemented for people presenting during adolescence. As a result, the number of people pursuing fertility preservation has increased dramatically over the years. 110 However, since we found that semen quality is already decreased prior to the initiation of GAHT, the majority of cryopreserved samples can only be used for invasive and expensive assisted reproductive techniques to establish a future pregnancy ( chapter 3 and 4 ).Therefore, it is very important to inform trans women about the influence of lifestyle on semen quality, specifically the negative impact of extensive tucking and wearing tight undergarments. Ideally, trans women should receive this information as early as possible, for example at time of referral to a gender identity clinic or during the diagnostic phase with the psychologist. In this way, trans women have enough time to adjust lifestyle in order to cryopreserve the best semen quality and hereby improve future reproductive options, without having to delay the start of GAHT. In addition, the option to keep the male gonads and, in a later stage, discontinue GAHT to naturally conceive with a female partner, should also be discussed with trans women. For those who can cope with a temporary cessation of GAHT, this is most likely the least invasive way to fulfill a desire for children and we observed positive results in trans women who have chosen this option in our study, described in chapter 5 . However, health care providers should be aware of the physical and psychological consequences of increasing serum testosterone levels after cessation of GAHT, which may be very burdensome for trans women, and pay extra attention to their clients’ wellbeing during this period. The group of transgender people that is most challenging in terms of the options for fertility preservation, are trans female adolescents in early puberty. The combination of their physical immaturity (incomplete spermatogenesis) and psychosocial immaturity (a desire for children not being in their scope of vision) at start of puberty suppression poses serious challenges on providing the best possible fertility care. The equipoise of commencing medical treatment to avoid progression of puberty, and delaying treatment to enable semen cryopreservation as only option for biological children may be stressful, as puberty is accompanied by irreversible and often unwanted physical changes such as a lowering of the voice and facial hair growth. Our observation that up to 21% indicated to, in retrospect, have been too young at start of medical treatment to make proper decisions regarding fertility ( chapter 2 ) raises complex questions on when and how to proceed with fertility impairing treatments. Internationally, there is increasing controversy over the provision of GAHT to adolescents, with the negative effect on fertility often cited as an argument for limiting adolescents' access to gender-affirming care. 108 However, since the majority felt that gender-affirming treatment was more important than staying fertile,