Technique
Description
Considerations
Future use
Sperm cryopreservation
Cryopreservation of ejaculated sperm through masturbation or electroejaculation
– Established technique
– Masturbation
– Post-pubertal
– Anaesthesia in case of electroejaculation
Male partner
Need of a donor oocyte and surrogate mother
Female partner
Intrauterine insemination or IVF/ICSI depending on sperm quality followed by embryo transfer in partner
Surgical sperm extraction
Percutaneous aspiration of sperm from testis or epididymis
– Established technique
– No masturbation
– Surgical procedure
– Post-pubertal
Male partner
Need of a donor oocyte and surrogate mother
Female partner
IVF/ICSI treatment followed by embryo transfer in partner
Immature testicular tissue cryopreservation
Surgical biopsy of testicular tissue
– Experimental
– Pre-pubertal or post-pubertal
– Possible at the moment of genital reconstructive surgery
Male partner
In vitro maturation and need of a donor oocyte and surrogate mother (not possible at the time of publication)
Female partner
In vitro maturation and IVF/ICSI followed by embryo transfer in partner (not possible at the time of publication)
Sperm Cryopreservation
Human sperm cryopreservation is a procedure to preserve sperm cells through freezing. For human sperm, the longest reported successful storage is 40 years [15]. This procedure is the simplest and most reliable method of male fertility preservation [16]. The sperm is obtained through masturbation, electroejaculation, or penile vibratory stimulation. Transgender women may find it difficult to masturbate in order to produce a semen sample for preservation. However, electroejaculation requires anaesthesia. Having semen samples stored reminds transgender women of their (male) past and may make some transgender women not feel as a complete woman [3, 4]. Depending on the sperm quality, the cryopreserved sperm can be used for future intrauterine insemination or to perform IVF/ICSI in the case of a female partner [10]. The need for IVF/ICSI, however, creates the necessity to start controlled ovarian stimulation in the female partner, followed by the aspiration of the egg cell. The embryo obtained can subsequently be transferred into the partner’s uterus. In the case of a male partner, a donor oocyte and a surrogate mother are both necessary.
Surgical Sperm Extraction
In cases of surgical sperm extraction, a percutaneous aspiration of sperm from the testis or the epididymis is performed [16]. Again, this is an established method in daily IVF practice. Although a solution for transgender women for whom masturbation is a burden, one must not forget that this is a surgical procedure [16]. The obtained spermatozoa can be used for future IVF or ICSI procedures in the case of a female partner. Again, in the case of a male partner, an oocyte donor and surrogate mother are both necessary in order to fulfil their child wish [12].
Testicular Tissue Cryopreservation
Testicular tissue cryopreservation means the freezing of the testicular tissue. For this technique a surgical biopsy of testicular tissue from pre- or post-pubertal transgender women is performed [16]. This option overcomes the need for masturbation and is possible in pre-pubertal boys [16]. It is a surgical procedure that can be combined with genital reconstructive surgery. Compared to the other two options, this is an experimental method. For future use, an in vitro maturation procedure, which is currently not clinically possible, or transplantation is necessary followed by assisted reproduction techniques. Transplantation can, however, restore the male endocrine environment, which clearly is an undesired effect for transgender women.
Future Fertility Preservation Options for Transgender Patients
Current research focuses on optimizing the in vitro maturation of spermatogonial stem cells [17]. An optimized culture model would allow the use of the currently banked testicular tissue without the need for transplantation. This would solve the side effect of having the unwanted hormones due to the transplanted tissue.
Apart from a testicular biopsy in transgender women to obtain spermatogonial stem cells, research to obtain artificial gametes through stem cells is ongoing [12, 18]. Obtaining functional gametes from induced pluripotent stem cells has been proven successful in mice [18]. Producing oocytes and sperm cells in human, starting from pluripotent stem cells derived from a skin biopsy (as an example), would be an important breakthrough [12]. This would be a possibility for those patients who cannot or have not stored their own gametes and currently need oocyte or sperm donation to fulfil their future genetically related child wish [2].
Transgender Gestation
In transgender women, being pregnant and giving birth are still not possible. The Swedish research unit of Brännström and his colleagues conducted a series of uterus transplants and reported a first live birth in 2014 [19]. This opens the possibility for assisted gestation for transgender women [20]. However, there are important medical concerns regarding uterus transplantation if introduced to transgender people [2, 6]. A challenging surgical procedure would be needed in order to change the anatomy of the male pelvis with the intention to perform a successful uterus transplantation. Moreover, immunosuppressive therapy would be necessary and is possibly contraindicated during a pregnancy [2], but that in itself would not be any different from a uterus transplantation for other indications resulting in the absence of the uterus or the presence of a non-functional uterus [19].
Transgender Parenting and Children
The above-mentioned options clearly show the opportunities [21] for transgender patients with a present or future genetically related child wish. All these possibilities, however, are strictly regulated by national legislations. Apart from legislation, some healthcare professionals still need to be convinced about the necessity and the ethical acceptability to preserve fertility in this patient group [10]. The underlying question is whether transgender parenting has a negative influence on the gender identity and the sexual orientation of a child [2, 22]. Few studies have addressed this question and conclusive evidence is scarce. Although the results from these studies are reassuring, long-term follow-up studies are undoubtedly needed. None of the studies published so far showed that children suffer to such an extent that would warrant a prohibition of transgender parenting [23]. Being transgender as a reason to interrupt contact between the transgender parent and his or her children, as is the case in some countries, is documented to be harmful for the children [2, 24]. It is shown that a child having a transgender parent may experience more transient and mild harassment than those who do not have a transgender parent [2, 24].
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