In the JournalsPerspective

Study highlights potential barriers to fertility preservation for transgender adolescents

Kenneth C. Pang

Among transgender adolescent patients in an Australian study, 62% of those who were assigned male sex at birth elected to pursue fertility preservation before seeking hormonal intervention — a much higher proportion than what has been reported in similar North American studies, according to researchers.

Kenneth C. Pang, MBBS (Hons), BMedSc, PhD, team leader and clinical scientist at Murdoch Children’s Research Institute in Melbourne, Australia, and colleagues said the “most likely explanation” for the contrast is a difference in access to fertility preservation.

“Our findings suggest that there is a strong intrinsic desire to undertake fertility preservation among transgender adolescents assigned male at birth and highlight the importance of offering affordable fertility preservation to these young people,” Pang told Healio.

Pang noted three North American studies published since 2016 that found that less than 5% of transgender adolescents elected fertility preservation. Pang said the publicly funded pediatric gender clinic where the current research was conducted has readily available fertility services, and is without certain health care barriers experienced by patients in places where the other studies were conducted.

“We were interested to know whether the low rates of fertility preservation that had been recently observed in North America reflected an intrinsic lack of desire for fertility preservation among transgender adolescents or instead arose due to health care barriers, such as high cost and limited availability,” Pang said.

At the clinic where the research was conducted, patients who were assigned male sex at birth have a relatively affordable option if they want to undergo fertility preservation before receiving hormonal intervention. Semen analysis costs approximately $66, annual sperm storage costs $132 and testicular biopsies are free, according to the study.

Pang and colleagues conducted a retrospective review of patients with gender dysphoria who had received gonadotropin-releasing hormone agonists and/or gender-affirming hormones from Jan. 1, 2003, through June 1, 2017. Among 102 patients who elected to receive fertility counseling before taking hormones, 53 were assigned male sex at birth, whereas 49 were assigned female sex. The mean age of the patients was 15.6 years.

None of the patients who were assigned female sex at birth pursued fertility preservation. Sixteen of them gave no reason for their decision, whereas 33 said they would revisit the topic at an older age.

In comparison, 33 of the 53 (62%) patients assigned male sex at birth elected fertility preservation. Among them, 22 successfully froze sperm, whereas the other 11 underwent testicular biopsies.

“We hypothesized that rates of fertility preservation uptake within our clinical population would be higher than those previously reported and better reflect the intrinsic desire for fertility preservation among transgender adolescents,” Pang said. “Mind you, we didn’t necessarily think that the rates among transgender adolescents assigned male at birth would be that high.” – by Ken Downey Jr.

References:

Chen D, et al. J Adolesc Health. 2017;doi:10.1016/j.jadohealth.2017.01.022.

Chiniara LN, et al. Arch Dis Child. 2019;doi:10.1136/archdischild-2018-316080.

Nahata L, et al. J Adolesc Health. 2016;doi:10.1016j.jadohealth.2016.12.012.

Pang KC, et al. JAMA Pediatr. 2020; doi:10.1001/jamapediatrics.2020.0264.

Disclosures: Pang reports receiving funding from the Royal Children’s Hospital Foundation. Please see the study for other authors’ financial disclosures.

Kenneth C. Pang

Among transgender adolescent patients in an Australian study, 62% of those who were assigned male sex at birth elected to pursue fertility preservation before seeking hormonal intervention — a much higher proportion than what has been reported in similar North American studies, according to researchers.

Kenneth C. Pang, MBBS (Hons), BMedSc, PhD, team leader and clinical scientist at Murdoch Children’s Research Institute in Melbourne, Australia, and colleagues said the “most likely explanation” for the contrast is a difference in access to fertility preservation.

“Our findings suggest that there is a strong intrinsic desire to undertake fertility preservation among transgender adolescents assigned male at birth and highlight the importance of offering affordable fertility preservation to these young people,” Pang told Healio.

Pang noted three North American studies published since 2016 that found that less than 5% of transgender adolescents elected fertility preservation. Pang said the publicly funded pediatric gender clinic where the current research was conducted has readily available fertility services, and is without certain health care barriers experienced by patients in places where the other studies were conducted.

“We were interested to know whether the low rates of fertility preservation that had been recently observed in North America reflected an intrinsic lack of desire for fertility preservation among transgender adolescents or instead arose due to health care barriers, such as high cost and limited availability,” Pang said.

At the clinic where the research was conducted, patients who were assigned male sex at birth have a relatively affordable option if they want to undergo fertility preservation before receiving hormonal intervention. Semen analysis costs approximately $66, annual sperm storage costs $132 and testicular biopsies are free, according to the study.

Pang and colleagues conducted a retrospective review of patients with gender dysphoria who had received gonadotropin-releasing hormone agonists and/or gender-affirming hormones from Jan. 1, 2003, through June 1, 2017. Among 102 patients who elected to receive fertility counseling before taking hormones, 53 were assigned male sex at birth, whereas 49 were assigned female sex. The mean age of the patients was 15.6 years.

None of the patients who were assigned female sex at birth pursued fertility preservation. Sixteen of them gave no reason for their decision, whereas 33 said they would revisit the topic at an older age.

In comparison, 33 of the 53 (62%) patients assigned male sex at birth elected fertility preservation. Among them, 22 successfully froze sperm, whereas the other 11 underwent testicular biopsies.

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“We hypothesized that rates of fertility preservation uptake within our clinical population would be higher than those previously reported and better reflect the intrinsic desire for fertility preservation among transgender adolescents,” Pang said. “Mind you, we didn’t necessarily think that the rates among transgender adolescents assigned male at birth would be that high.” – by Ken Downey Jr.

References:

Chen D, et al. J Adolesc Health. 2017;doi:10.1016/j.jadohealth.2017.01.022.

Chiniara LN, et al. Arch Dis Child. 2019;doi:10.1136/archdischild-2018-316080.

Nahata L, et al. J Adolesc Health. 2016;doi:10.1016j.jadohealth.2016.12.012.

Pang KC, et al. JAMA Pediatr. 2020; doi:10.1001/jamapediatrics.2020.0264.

Disclosures: Pang reports receiving funding from the Royal Children’s Hospital Foundation. Please see the study for other authors’ financial disclosures.

    Perspective

    Gina M. Sequeira

    This article highlights the pretty stark differences between fertility preservation and utilization in Australia vs. here. I agree with them that one of the biggest differences is related to access. Specifically, when I have conversations about fertility preservation with my patients, cost for those patients who are interested is one of the biggest barriers.

    Because the researchers included some cost information in this study, I did some hypothetical math. Basically, based on the numbers that they cited in Australia, a young person who's assigned male sex at birth can provide three sperm samples and store their sperm for one year for a total of $330. In our institution, which does provide access to this service for our transgender patients, it's nearly four times that cost to provide three samples and then store for a year. And obviously, for the majority of young people, this is not a store-for-a-year type of thing; it often requires multiple years of storage, prior to use. I think they highlight in this study the massive factor that cost plays for many young people and their families and will impact whether something like this is feasible or not.

    I’ve had many young people and their families when I talk with them about this process who are fearful because there's a lot that we don't know about what the future will hold. It is a frequent occurrence that I have young people in and their families ask what I think they should do. Honestly, it's a really hard question to answer as a provider, because I think it’s such an individual decision. As the data in this paper highlight, young people have lots of different reasons why they're uncomfortable going forward with this process or that they declined to participate. It’s really hard for me as a provider to talk about with young people.

    Insurance cost is one big barrier for many of my patients. The lack of insurance coverage for this process in the United States is something that is a really big factor for many of my patients in deciding whether or not to go forward with this and I think good studies like this will highlight the importance of us kind of pushing for insurance companies in the U.S. to cover this service for our transgender patients.

    Disclosure: Sequeira reports no relevant financial disclosures.

    • Gina M. Sequeira, MD, MS
    • Adolescent medicine fellow
      UPMC Children’s Hospital of Pittsburgh

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