Iris de Nie

22 C H A P T E R 2 For trans feminine people, currently available options for fertility preservation include cryopreservation of ejaculated spermatozoa, or harvested from testicular tissue, or through vibratory-/electrostimulation. These options require complete spermatogenesis which only develops during puberty, under the influence of increasing intratesticular testosterone levels. Due to the start of medical transition in early puberty, spermatogenesis is often not yet present. Other barriers for fertility preservation in trans feminine people are that semen cryopreservation requires masturbation which may be stressful for some, and that testicular sperm extraction is an invasive procedure which requires anaesthesia and surgery. 54 Decision making about fertility can be very difficult for adolescents since their early age and subsequently intellectual, emotional, and social immaturity may impede prediction of future desires regarding fertility and family planning. Besides, for a lot of people the desire of having children is a life-phase bound subject which may develop later in life. Recent studies found that up to 80% of transgender youth expressed an interest in having a family, but the need for biologically related children was questioned and only a small percentage reported to be frustrated if biological parenthood would not be feasible. 55,56 However, health care providers often worry that transgender adolescent’s views regarding parenthood might change over time, and also many adolescents acknowledge that this may happen. 56-59 Coming of reproductive age, combined with improved body satisfaction and mental health, might result in an improved capability to establish romantic relationships and consider future family building. In transgender adolescents, data on the potential change in wishes and desires regarding fertility, family building and the importance of biological parenthood, when coming of reproductive age, are lacking. Hereby, the long-term consequences of acquired infertility in transgender adolescents who have now reached adulthood remain still unknown. Therefore, this study aims to investigate how adults, who started gender-affirming treatment during adolescence, reflect on their reproductive wishes in the past and how this influenced their choices regarding family building in the present.With this knowledge, we aim to improve fertility counselling for transgender adolescents and their families and appropriately support them in making these difficult decisions. METHODS Study population Gender diverse adolescents who presented at the Center of Expertise on Gender Dysphoria in Amsterdam between 1989 and 2000 and were treated with GAHT, were recruited for participation. As well as gender diverse adolescents who commenced medical treatment with gonadotropin-releasing hormone agonist (GnRHa) prior to GAHT, at least 9 years ago. Between December 2019 and June 2021, eligible individuals were approached through mail with information about the study and an invitation to participate. Those who were interested in participation were informed in more detail via telephone, before obtaining written informed consent.People were not eligible for inclusion if they did not start medical