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79 SUCCESSFUL RESTORATION OF SPERMATOGENESIS FOLLOWING GENDER-AFFIRMING HORMONE THERAPY 5 in some of these individuals. More noteworthy though is our observation that three trans women who had no sperm on their initial semen collections subsequently produced sperm afterwards. This is, to our knowledge, the first conclusive evidence that spermatogenesis can recover following GAHT cessation. In summary, our data strongly suggest that the negative impact of GAHT on spermatogenesis can be reversed and cast into serious doubt previous claims that such treatment inevitably leads to permanent infertility. Our findings also have important implications for fertility counselling in transgender health. For example, many trans women receiving GAHT who still have their gonads believe that they are permanently infertile, as do their clinicians. Our results will help such individuals make more informed reproductive choices moving forwards. Similarly, for trans women wanting to commence GAHT in the future, our findings may influence their decision-making regarding fertility preservation (e.g. , some may be less inclined to freeze their sperm, knowing that they may be able to produce sperm should they stop GAHT later on). Nonetheless, we would still recommend sperm cryopreservation prior to GAHT for anyone who might want to be a genetic parent in the future. After all, recovery of spermatogenesis took many months in some cases, during which time testosterone levels increased and are likely to have had negative physical and psychological consequences. Moreover, invasive testicular sperm extraction was required in one case, and > 55% (5/9) of individuals had impaired semen quality after stopping GAHT.