Iris de Nie

78 C H A P T E R 5 Figure 1. Relationship between GAHT duration and time when spermatozoa first identified after stopping GAHT. Note: Patient 3 was excluded from this analysis given that the first semen analysis was significantly delayed (see Table 1). DISCUSSION The prevailing dogma in transgender health is that GAHT in trans women “eventually results in irreversible infertility”. 3 This helps to fuel controversy over provision of GAHT, especially to adolescents, and is reflected in arguments to support legal efforts to restrict young people’s access to gender-affirming care. 108 While there are numerous reports that GAHT impairs spermatogenesis, current evidence indirectly suggests this impact may be transient. For example, Alford et al. recently described a trans woman who – prior to gender-affirming genital surgery and following a course of FSH and clomiphene – successfully cryopreserved sperm from semen specimens collected 6-10 weeks after GAHT cessation. 109 Similarly, Adeleye et al. reported that three trans women who stopped GAHT all had mature sperm present on semen analysis 3-6 months later. 39 However, for all four of these trans women, it is unclear to what extent their spermatogenesis was impaired by GAHT in the first place. As noted earlier, up to 40% of trans women have evidence of normal spermatogenesis at the time of gonadectomy despite GAHT. 107 Thus, it is conceivable that spermatogenesis in each of these four trans women was never actually impaired, and knowing whether GAHT reversibly affected their spermatogenesis is not possible. Our observation that six trans women had sperm identified from their initial semen analyses after stopping GAHT provides further indirect evidence that GAHT-induced impairment of spermatogenesis can be reversible. After all, the probability that at least one of these six patients had completely stopped producing mature sperm due to GAHT is very high (1-0.4 6 = 99.6%), indicating that spermatogenesis is likely to have recovered