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55 A COHORT STUDY ON FACTORS IMPAIRING SEMEN QUALITY IN TRANSGENDER WOMEN 4 this study, the following cutoff values were used: TMSC > 2million is suitable for intra uterine insemination (IUI), TMSC > 1and < 2 million is suitable for in vitro fertilization (IVF) and TMSC < 1 million is suitable for intra cytoplasmatic sperm injection (ICSI). Serum hormone levels were assessed in the laboratory for Endocrinology of Amsterdam UMC. Statistical analysis Baseline characteristics are presented as mean with standard deviation (SD) when normally distributed, and as median with interquartile range (IQR) when non-normally distributed. Qualitative data are presented as number with percentage. Since participants cryopreserved multiple semen samples, the collective semen parameters were averaged and their means were used for statistical analysis. Semen characteristics from our cohort were compared with data from the general population of unscreened men, using Wilcoxon signed rank tests. 10 By using the reference values for human semen as determined by theWorld Health Organization (WHO), semen quality was categorized in the following descriptive diagnoses: normozoospermia, asthenozoospermia, oligozoospermia, oligoasthenozoospermia, or azoospermia. 11 Azoospermic transgender women were excluded from analysis of sperm concentration, total sperm number, and percentage progressive motility. For post-thaw semen quality, TMSC was calculated per vial volume of 0.5 mL and categorized as described above. Since data on semen quality were strongly right-skewed, logistic regression analyses were used to assess the influence of factors known to have a negative impact on semen quality in cisgender men, (i.e. age at time of semen cryopreservation, alcohol consumption, smoking, cannabis use, BMI, a history of urological problems, and a history of depression and anxiety), as well as factors that may specifically impact semen quality in transgender women (i.e. previous feminizing hormone use, ejaculation frequency, wearing of tight undergarment, and tucking). 36-38,85,87 Semen quality was expressed in five semen parameters (semen volume, sperm concentration, total sperm number, progressive motility, and TMSC), of which TMSC was used as main outcome measurement since it takes the absolute value of three semen parameters into consideration simultaneously. Based on results from a previous study on indicators for the severity of male factor infertility, TMSC was dichotomized using 5 million as cut-off value. 12,13 The other semen parameters were dichotomized using WHO reference values (semen volume < 5 ml, sperm concentration < 15 million per ml, sperm motility < 32%, and total sperm number < 39 million). 10 Ejaculation frequency, wearing tight undergarment, and tucking were each divided in three categories: low ( < 6x/month), average (6-12x/month), and high ( > 12x/month) ejaculation frequency; never, sometimes, and always wearing tight undergarment; never, sometimes (1-8x/month), and often ( > 8x/month) tucking. Firstly, crude analyses were performed, then multivariable logistic regression analyses were conducted, correcting for the other determinants. Both crude and corrected odds ratios (OR) with 95% confidence intervals (95% CI) are presented. STATA Statistical Software, version 15.1 (Statacorp, College Station, TX, USA) was used for statistical analyses.