Iris de Nie

38 C H A P T E R 3 INTRODUCTION Gender dysphoria refers to the distress that results from a conflict between a person’s assigned gender at birth and one’s gender identity. 70 People assigned male at birth who identify as male are defined as cis men, and birth-assigned males who identify as female are defined as trans women. In the Netherlands, the prevalence of gender dysphoria in birth-assigned males is approximately 1 in 2,800. 71 Transgender people may start medical treatment to align their physical characteristics with their gender identity, including gender-affirming hormone treatment and gender-affirming surgery. Hormone treatment for trans women consists of anti-androgens combined with estrogens in order to achieve feminization. However, hormone treatment is accompanied by a loss of reproductive capability, and while spermatogenesis might restore after discontinuation of prolonged treatment with anti-androgens and estrogens, it has not been well studied. 29,72 After gender affirming surgery, involving penectomy and bilateral orchiectomy combined with vaginoplasty, reproductive loss will certainly be permanent. Many trans women desire to start a family and parent genetically related offspring, just like many other people of reproductive age. A recent study among trans women showed that 69.9% had an interest in having children in the future and 76.6% considered fertility preservation before starting a medical transition. 73 For several years, scientific medical societies in the field of transgender health have emphasized the need to inform about the effect of the medical transition on fertility and the currently available options for fertility preservation. 1,2 The equipoise of commencing medical transition, and fertility preservation as the only option for biological children, may be stressful. In trans women, the option for fertility preservation is semen cryopreservation. In case of azoospermia or other anatomic variations or emotional concerns, testicular sperm extraction (TESE) is possible but not always successful. Once cryopreserved sperm has been stored, ART enable trans women to have genetically related children with their female partner or via 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 IUI, while semen of low quality requires a more invasive and expensive technique such as IVF or ICSI. 32 Although data on semen characteristics in trans women show a high incidence of impaired semen quality, these studies report on a 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 in order to improve semen quality before fertility preservation. The purpose of this study is to assess semen quality in our large cohort of trans women, to evaluate semen adequacy for the different types of ART and to identify life style factors influencing semen quality.