Andrological care in transgender women: Perspectives for (new) life after transition

SUMMARY OF MAIN FINDINGS In chapter 2 we found that, for various reasons, none of the participants pursued fertility preservation prior to initiation of treatment, but a substantial percentage indicated that, in retrospect, they would have wanted to do so. The majority of the study population reported to currently have a desire for children, to desire children in the future, or to have children. Furthermore, many participants advised adolescents who are currently in the process of starting treatment, to pursue fertility preservation and hereby keep all options for future family building open. As described in chapter 3, we found that at time of semen cryopreservation, semen quality in trans women is significantly decreased compared to WHO data on semen quality in the general population. Furthermore, the vast majority of semen samples were only suitable for invasive and expensive reproductive techniques (IVF/ICSI) to establish a pregnancy in the future. Although smoking and a higher age at time of fertility preservation were found to correlate with an impaired progressive motility, it was insufficient to explain the overall decreased semen quality in this cohort. In chapter 4, semen quality was also impaired but no negative impact of age, BMI, smoking, alcohol consumption, cannabis use and medical history on the semen parameters was observed. It was found that always wearing tight undergarments and a tucking frequency of more than 8 times a month were associated with having a total motile sperm count below 5 million. The aim of the study described in chapter 5, was to determine whether loss of spermatogenesis can be reversed after GAHT is ceased. We included nine trans women, each of whom stopped GAHT for reproductive purposes, and we assessed their subsequent ability to produce sperm. In all nine individuals viable spermatozoa were found (3-27 months after cessation of GAHT). These results strongly suggest that the negative impact of GAHT on spermatogenesis can be reversed. In the study described in chapter 6, we assessed if there may still be options for fertility preservation in testicular tissue obtained during GAS. It was found that in a small percentage of trans women who initiated medical treatment in Tanner stage 4 or higher, spermatozoa could have been harvested from the orchiectomy specimen at time of GAS. In addition, the vast majority (> 85%) of trans women in our cohort could still opt for cryopreservation of testicular tissue harboring spermatogonial stem cells. We found that initiation of medical treatment in early-pubertal adolescents (Tanner stage 2-3) limits the ability to retrieve mature spermatozoa that can directly be used for assisted reproductive techniques, since in these orchiectomy specimens only immature germ cells were present. To assess the safety of hormone treatment in terms of testicular cancer risk, we conducted a study to evaluate the incidence of testicular cancer in trans women using GAHT. As described in chapter 7, we observed a total of three testicular cancer cases in our cohort, of which two were discovered due to symptoms and the third was encountered during routine histopathological analysis of the bilateral orchiectomy specimen. Based on agespecific incidence rates in cis men, a similar amount of testicular cancer cases would have been expected, which suggest that testicular cancer risk in trans women is comparable to the risk in cis men. In the study described in chapter 8, we assessed the prostate cancer incidence in trans women using GAHT and we hereby studied the potential preventive effect of androgen deprivation on the occurrence of prostate cancer. We found a 5-fold decrease in prostate cancer risk in trans women using GAHT compared with the general male population of similar age.