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45 IMPAIRED SEMEN QUALITY IN TRANS WOMEN 3 Table 2. Effect of patient-related factors on semen parameters Semen volume < 1.5 ml OR (95% CI) Sperm concentration < 15x10 6 OR (95% CI) Total sperm number < 39x10 6 OR (95% CI) Progressive motility < 32% OR(95% CI) Age at time of fertility preservation - years 0.96 (0.91-1.01) 1.03 (0.99-1.07) 1.00 (0.97-1.04) 1.04 (1.00-1.08)* BMI – kg/m² 1.01 (0.93-1.11) 1.05 (0.97-1.13) 1.04 (0.97-1.12) 1.04 (0.97-1.12) Alcohol - yes/no 0.96 (0.47-1.89) 0.59 (0.34-1.04) 0.71 (0.41-1.24) 0.85 (0.49-1.48) Smoking - yes/no 2.21 (0.95-5.17) 1.33 (0.62-2.82) 2.01 (0.95-4.27) 2.35 (1.06-5.21)* Cigarettes per day (in smokers) 1.09 (0.98-1.22) 1.03 (0.94-1.14) 1.02 (0.93-1.13) 1.11 (1.00-1.24) Cannabis use - yes/no ∞ 0.80 (0.36-1.91) 0.79 (0.34-1.85) 0.40 (1.15-1.04) Previous hormone use - yes/no 1.55 (0.40-5.94) 2.94 (0.91-9.55) 2.64 (0.81-8.56) 2.50 (0.77-8.11) History of anxiety or depression - yes/no 1.16 (0.47-2.83) 1.83 (0.89-3.76) 1.41 (0.69-2.91) 0.88 (0.41-1.85) History of inguinal hernia repair or cryptorchidism - yes/no 0.85 (0.17-3.81) 0.58 (0.16-2.17) 0.52 (0.14-1.95) 1.07 (0.34-3.37) * p-value < 0.05 using logistic regression analyses. At time of writing, six trans women in our cohort had used their cryopreserved semen a median 6 years (range 2-18 years) after cryopreservation. One individual decided to donate two vials to a befriended couple. The other five trans women successfully used their semen with their female partner. Two couples conceived through IUI, one couple through IVF and the other two couples through ICSI. DISCUSSION As far as we are aware, this is the largest cohort study showing an impaired semen quality in trans women at time of fertility preservation. In only 26.4% of the post-thawed samples was semen quality considered adequate for IUI. Although smoking and a higher age did affect progressive motility, it did not provide an explanation for the overall reduced quality in this cohort. Therefore, these results suggest the existence of one or more transgender specific factors that negatively influence semen quality. A high percentage of trans women had semen parameters below the WHO reference values when compared with a study on semen quality of young men from the general population, i.e. a sperm concentration below 15 million/ml (33.5% versus 17.5%) and progressive motility below 32% (36.9% versus 14.4%). 80 Furthermore, we observed a higher incidence of azoospermia (8.1% versus 0.8%) compared to the study of Hart et al. Our findings are in line with previous studies on semen quality in trans women, which also showed a high incidence of azoospermia, oligozoospermia and asthenozoospermia. 33-35 Only one of these studies collected data on personal behavior, feelings of depression, anxiety and stress, as well as serum hormone concentrations. However, none of the characteristics were able to explain the reduced semen quality in trans women. 35 Despite the significantly larger sample size, our cohort study demonstrates similar observations.