THE IMPORTANCE OF FERTILITY PRESERVATION IN THE TRANSGENDER POPULATION
Niki Parikh, MD, MBA, MSBA1, Glenn M. Cannon, MD2, Asma Chattha, MBBS3, Patricio Gargollo, MD1, Kyle E. Orwig, PhD4, T. Brooke McClendon, PhD4, David Walker, Bachelors5, Candace Granberg, MD1.
1Mayo Clinic Urology, Rochester, MN, USA, 2UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA, 3Mayo Clinic Division of Pediatric Gynecology, Rochester, MN, USA, 4UPMC Center for Reproduction and Transplantation, Pittsburgh, PA, USA, 5Reproductive Endocrinology & Fertility Laboratory, Rochester, MN, USA.
BACKGROUND: The transgender population has long been marginalized by society. Societal stigmata, fear to seek care, and dearth of provider knowledge regarding transgender health issues has caused disparities to widen. The purpose of this case study is to call to attention the often-overlooked aspect of pediatric transgender care: the importance of fertility preservation prior to instituting gender-affirming therapy.METHODS: Twenty-two genetically XY transgender females, followed by their multidisciplinary transgender care teams, were interested in starting hormone therapy due to impending onset and/or progression of puberty. Fortunately for these patients, their physicians were aware of fertility struggles after undergoing hormone therapy.RESULTS: Sperm cryopreservation via open gonadal biopsy, testicular tissue cryopreservation (TTC), and semen sample (when age/maturity-appropriate) were discussed. Though requiring surgery, biopsy/TTC relieves patients of the psychological impact of semen sample production. Under IRB approval, 20 patients (median age 12 years, range 10-16 years) underwent TTC (Figure 1). Two patients (both age 16 years) opted for semen sample. All TTC patients had success with spermatogonial stem cells cryopreserved for future patient use.CONCLUSIONS: Gender affirming procedures and hormone therapy affect the long-term reproductive potential of transgender individuals. While cost concerns and insurance coverage regarding oncofertility is a prominent area of discussion, the transgender community is often excluded. With more individuals beginning medical and surgical therapy at a younger age, fertility preservation discussions are essential but often overlooked, depriving these individuals the joy of becoming a biological parent. As health care providers, addressing psychological, emotional, physical, and spiritual needs of patients is crucial, and fertility is a key aspect of this care. TTC can be safely done in pediatric populations under IRB approval, though research is necessary to expand beyond current experimental stage of tissue-development.
Figure 1: Intraoperative images from testicular biopsy. Location of transverse incision on scrotum (A), testicular parenchyma delivered and sent for pathologic analysis (B), tunica albuginea closed with running 6-0 PDS (C) 
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