Iris de Nie

98 C H A P T E R 6 consider an attempt for cryopreservation of spermatozoa from a semen sample, obtained through ejaculation. However, it is unknown if spermatogenesis can recover if GAHT is stopped and how much time is needed for this purpose. Furthermore, it should not be underestimated that cessation of GAHT will result in increased testosterone levels which is likely to have negative physical and psychological consequences, and that masturbation is often not an option in transgender women due to severe genital dysphoria. A disadvantage of spermatozoa that are harvested from testicular tissue, is that they are not suitable for a minimally invasive and inexpensive IUI and can only be used for ICSI. 32 In addition, such ICSI treatments using surgically obtained spermatozoa are not always successful, since the cumulative ongoing pregnancy rate per cycle has been reported to be 22.8% and the live birth rate 22.3%. 120 Therefore, cryopreservation of a semen sample prior to initiation of GAHT remains the preferred method of fertility preservation in transgender women and harvesting germ cells from orchiectomy specimens might only be considered an alternative in those for whom this is not an option. The lumina of the seminiferous tubules in those who initiated medical treatment in Tanner stage 2-3 were all either half-open, or absent. This observation might be explained by the immaturity of testicular tissue in early puberty, since an open lumen develops parallel to the development of spermatogenesis under the influence of increasing intratesticular testosterone levels. The fact that germ cells were encountered in all orchiectomy specimens from transgender women who initiated medical treatment as adolescent, is reassuring. Decision making about fertility can be very difficult for adolescents since their intellectual, emotional, and social immaturity may impede assessment and prediction of future desires regarding fertility and family planning. A recent study among transgender youth showed that 67% of young transgender women expressed a desire for future parenthood, but only 7% indicated to be frustrated if biological parenthood would not be feasible. 55 Another study, however, reported that 48% of transgender adolescents acknowledged that their desires regarding parenthood might change over time. 57 Reduced levels of gender dysphoria and improved mental health might result in an improved capability to establish romantic relationships and consider future family building. Our observation that immature germ cells remain present in testicular tissue during GAHT suggest that transgender adolescents still have potential options for fertility preservation after initiation of treatment by cryopreserving testicular tissue from orchiectomy specimen obtained during gGAS. Cryopreservation of testicular tissue containing spermatogonial stem cells is mostly offered to pre-pubertal boys with cancer, prior to undergoing gonadotoxic therapies such as chemo- and radiotherapy, but some clinics also offer this option to transgender adolescents. 63 In the absence of complete spermatogenesis, the purpose of spermatogonial stem cell preservation in cisgender adolescents is to transplant these cells back into the testes years later, via injection into the rete testis space that is contiguous with all seminiferous tubules. Spermatogonial stem cells have the potential to colonize the testicular niche and regenerate spermatogenesis. 121 However, re-transplantation is not a feasible option for transgender women, as they will most likely use lifelong GAHT and many will undergo bilateral orchiectomy. Therefore, spermatogonial stem cell preservation will only be a viable method for fertility preservation in transgender women when other