Iris de Nie

14 C H A P T E R 1 of gender-affirming hormone use is a decrease or even an absence of spermatogenesis, resulting in an impaired reproductive function. 2 Since it has been shown that prolonged exposure to GAHT leads to spermatogenic involution, a decreased diameter of seminiferous tubules, and increased peritubular hyalinization, these effects may be irreversible. 27,28 After bilateral orchiectomy or vaginoplasty reproductive loss is certainly permanent. 29 Fertility and family building Although gender-affirming treatment significantly improves quality of life, the loss of reproductive function is an unwanted consequence for those with a (future) desire for children. In many countries, including the Netherlands, there were until recently strict transgender laws in place which required sterilization in order to be able to change gender on official documents and in population registries. 30 Therefore, almost all trans women visiting our gender identity clinic underwent this procedure until 2014. Loss of fertility was considered the price to pay for transition and options for fertility preservation were not discussed on a structural basis. Very little is known about how transgender people experienced the ‘choice’ of having to give up their fertility to be able to transition, and how they feel about living with the consequence of infertility. Especially in people who started their transition when they were younger than 21 years, when fertility or a future desire to have children may not have been in their scope of vision. Fortunately,many countries nowabandoned laws that required sterilization for legal gender recognition and therefore, fertility and future family building can now be openly discussed with transgender people. 30 Over the years, a general consensus has been developed on the need to provide counselling about the effect of the medical transition on fertility and the currently available options for fertility preservation. 1 The currently available options for fertility preservation in trans women include cryopreservation of ejaculated spermatozoa, or spermatozoa harvested from testicular tissue, or through vibratory- or electrostimulation. 31 Cryopreservation of ejaculated sperm is the most recommended option for fertility preservation, as it is least invasive and provides the best semen quality. Once cryopreserved sperm has been stored, assisted reproductive techniques enable trans women to have genetically related children with their female partner or a surrogate.Which technique is optimal, is determined by the post-thaw semen parameters: semen of good quality can be used for minimally invasive and inexpensive intrauterine insemination (IUI), while semen of low quality requires a more invasive and expensive technique such as in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). 32 Although data on semen characteristics in trans women show a high incidence of impaired semen quality, these studies report on relatively low number of people. 33-35 The etiology could not be identified in these studies due to the small sample size and a lack of endocrine laboratory results and complete clinical data on certain lifestyle factors known to influence semen quality, such as age, obesity and cigarette smoking. 36-38 With knowledge of the factors negatively influencing semen parameters in trans women it could be possible to optimize counseling about how to improve lifestyle before fertility preservation and hereby help trans women in their wish to parent genetically related offspring by cryopreserving semen suitable for the most patient-friendly strategy.