Iris de Nie

46 C H A P T E R 3 Many trans women desire to start a family and prefer to use their gametes for this purpose. 73 This is in direct conflict with their desire for medical transition, as anti- androgens, estrogens and gender-affirming surgery impair their reproductive function. Semen cryopreservation enables trans women to parent genetically related offspring later in life and they are strongly recommended to cryopreserve semen prior to hormone treatment as spermatogenesis might not restore, or only partially, after discontinuation. Furthermore, discontinuation of hormone treatment can be quite stressful for trans women due to the returning effects of testosterone. Therefore, trans women have to reflect on their reproductive wishes at a young age and early in the transition process. Early banking of sperm enables trans women to have future reproductive options. However, a decreased semen quality limits the number of ART that can be used. A high post-thaw TMSC is preferred because semen can be used for IUI and the insemination can take place in the natural cycle of a cis woman. Therefore, it is an uncomplicated and noninvasive technique, with minimal monitoring and risks. IVF or ICSI, however, may have serious consequences and risks for the cis woman undergoing this treatment as it involves controlled ovarian stimulation and an oocyte retrieval procedure. 81 In our cohort, more than 70% of the thawed samples were only suitable for IVF or ICSI. Previous studies already demonstrated a high variation in the cryosurvival of semen, mainly depending on pre-freeze motility and total sperm count. 82-84 Although, because of the cryopreservation process, post-thaw motility is always decreased compared to pre-freeze values, it has been shown that higher pre-freeze sperm counts result in an increased potential to withstand cryopreservation. Conversely, lower pre-freeze semen quality results in an even lower post-thaw motility, underlining the importance of improving semen quality by improving certain lifestyle factors prior to the fertility preservation process. 83 The question arises of how we can counsel trans women to take the appropriate action to optimally cryopreserve their sperm. Multiple studies, performed in cis men, established the negative effect of a higher age, obesity, cigarette smoking and high levels of alcohol intake on semen quality. 36-38,85 In our cohort, some effects of these lifestyle factors were observed; smoking and a higher age correlated with an impaired progressive motility. However, as shown in Table 1, compared with data from the general Dutch population of similar age, our cohort consisted of generally healthier individuals in terms of BMI, alcohol intake, smoking and cannabis use. 74 Other factors associated with a lower semen quality are psychological stress, depression and anxiety: previous studies showed a significantly negative effect of these factors on sperm concentration, motility and morphology. 86,87 Trans women desiring a medical transition might experience more stress compared to cis men but our data did not show a decreased semen quality in trans women who reported suffering from anxiety or depression. Hypothetically, semen quality in trans women is affected by transgender specific factors, such as a low frequency of masturbation, gender-affirming hormone use, keeping the genitals tight against the body or even bringing the testicles into the inguinal canal (tucking). 88-91 Trans women with previous gender-affirming hormone use in our