Iris de Nie

21 REFLECTING ON THE IMPORTANCE OF FAMILY BUILDING AND FERTILITY PRESERVATION 2 INTRODUCTION Within the last two decades, gender-affirming care for transgender youth has become widely available. 47 One of the topical debates in adolescent transgender care concerns the difficulty of making decisions regarding fertility at an early age, since medical treatment for gender dysphoria negatively affects reproductive function. As we are aware of the diversity, in this paper people assigned female at birth with a male gender identity are referred to as trans masculine, whereas people assigned male at birth with a female gender identity are referred to as trans feminine. In the late 1980s, our center was the first worldwide to start with medical treatment for transgender adolescents, often referred to as the Dutch approach. 48 Initially, this treatment was solely offered to adolescents aged 16 years or older and consisted of gender-affirming hormones (androgens for trans masculine people, estrogens and anti-androgens for trans feminine people). Since 2000, gender-affirming hormone treatment (GAHT) of transgender adolescents can be preceded by a phase of puberty suppression, through administration of gonadotropin-releasing hormone agonist (GnRHa) when they have entered early puberty (from Tanner Stage 2 onwards). 49 The rationale of treatment with GnRHa is to prevent secondary sex characteristics development (e.g. lowering of voice, facial hair growth, breast growth, menstrual cycle) and hereby give adolescents time to explore options and to live in the experienced gender before making a decision to proceed with treatments that may be irreversible. 1 Although early medical intervention has proven its effectiveness, an important limitation of both puberty suppression and gender-affirming hormone treatment (GAHT) is that they negatively affect reproductive function, as they inhibit gamete maturation. 50 After genital gender-affirming surgery (gGAS) including gonadectomy, reproductive loss is permanent. Until 2014, similar to many other countries, strict transgender laws were in place in the Netherlands which required sterilization for legal gender recognition. Since the abolition of this law,health care providers are strongly recommended to counsel transgender adolescents about the options for fertility preservation prior to initiating puberty suppression and GAHT, as well as before undergoing gGAS. 1,51 For trans masculine people, currently available options for fertility preservation include oocyte vitrification and embryo cryopreservation. At our center, vitrification of oocytes can be performed in people of 16 years or older, either prior to commencing testosterone treatment or after 3 months of discontinuation. Since this procedure requires ovarian hyperstimulation with monitoring via transvaginal ultrasound and an ovum pickup procedure, it often causes large amounts of distress. 52 Embryo cryopreservation is only recommended in people with a stable long-term relationship and may, therefore, not be suitable for adolescents. Some trans masculine people also consider becoming pregnant as an option. However, this is only considered in a small number of people and it may cause major distress due to gender dysphoria. 53