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Fertility Preservation in Transfeminine Adolescents - Case Series of Combined Testicular Biopsy/Sperm Extraction and Histrelin Acetate Subcutaneous Implant Placement
Eric M. Bortnick, MD, Ellis Barrera, BA, Rachel Locks, MD, Jessica Kremen, MD, Richard Yu, MD PhD.
Boston Childrens Hospital, Boston, MA, USA.

BACKGROUND: Fertility preservation (FP) is becoming an increasingly important aspect in the care of transgender patients in whom Gender Affirming Medical Treatment (GAT) may begin before testosterone driven puberty has been completed. While there are overall few studies that can be used to guide conversations about long-term effects of GAT, there are concerns that GAT could negatively impact fertility. As a result, prior studies have shown low utilization of FP in this population, with avoidance of delay in starting GAT cited as one of the most common reasons for not undergoing FP. Therefore, it is possible that strategies to mitigate delay in commencement of GAT can facilitate higher utilization of FP. In this case series, we describe our institution's experience with the combination surgical procedure of Testicular Biopsy/Sperm Extraction for FP and Histrelin Acetate (Supprelin) Subcutaneous Implantation for commencement of GAT. METHODS: A retrospective review of transfeminine adolescents at our institution from 2010-2022 who underwent combination surgery of testicular biopsy/sperm extraction for FP and Supprelin implantation for GAT was performed. Outcomes of interest included successful sperm retrieval for storage, age at first visit to our institution's Transgender Multispecialty Service Health clinic (GeMS), age at time of combination surgery, testicular volume at time of combination surgery, and age when hormonal therapy was prescribed. Testosterone, LH, FSH, and Inhibin B values prior to combination surgery were also obtained. This study was approved through institutional board review. RESULTS: Ten patients from 2017-2022 underwent combination testicular biopsy/sperm extraction and Supprelin Implantation. Successful sperm retrieval and storage was achieved in all ten patients. Median age at combination surgery was fourteen years 5.5 months (range 12y5m-16y8m). Median time from first GeMS visit to combination surgery date was five months (range 2-38m). Median time from therapy prescription to combination surgery was two months (range 2-5m). Median time from first GeMS visit to therapy prescription was 0.5 months (range 0-34m). Mean testicular volume at time of combination surgery was 13.2cc (SD 3.38cc, range 8-17cc). Average testosterone level was 301.60 (SD 173.04), LH 3.00 (SD 1.25), FSH 3.33 (SD 1.71), Inhibin B 208.50 (SD 87.44). CONCLUSIONS: Combination surgery for FP and GAT is feasible at early ages in this patient population, which leads to short delays in the start of GAT. Testicular volume and endocrine markers can provide preoperative insight into successful sperm retrieval during testicular biopsy. Future prospective studies with protocol driven factors are needed to identify which patients will have successful sperm retrieval so that optimal timing of FP can be performed and not delay commencement of GAT.


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